Present on Admission Reporting Guidelines
Comprehensive guidance for assigning Present on Admission (POA) indicators in ICD-10-CM coding for accurate claim reporting and documentation.
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Introduction
Understanding POA Guidelines
These guidelines supplement the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837 Institutional).
The POA guidelines are not intended to replace any guidelines in the main body of the ICD-10-CM Official Guidelines for Coding and Reporting. Rather, they provide guidance on how to apply the POA indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines.
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Requirements
General Reporting Requirements
All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information must comply with these guidelines.
Definition
Present on admission is defined as present at the time the order for inpatient admission occurs.
Scope
Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.
Application
POA indicator is assigned to principal and secondary diagnoses and the external cause of injury codes.
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Options
POA Reporting Options and Definitions
Y – Yes
Present at the time of inpatient admission
N – No
Not present at the time of inpatient admission
U – Unknown
Documentation is insufficient to determine if condition is present on admission
W – Clinically Undetermined
Provider is unable to clinically determine whether condition was present on admission or not
Unreported/Not Used
Exempt from POA reporting
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Timeframe
Timeframe for POA Identification
There is no required timeframe as to when a provider must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis for a period of time after admission.
In some cases, it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission. Determination will be based on the applicable POA guideline or on the provider's best clinical judgement.
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Assignment Guidelines
Assigning the POA Indicator
01
Exempt from Reporting
Leave the "present on admission" field blank if the condition is on the list of ICD-10-CM codes for which this field is not applicable.
02
POA Explicitly Documented
Assign Y for any condition the provider explicitly documents as being present on admission. Assign N for any condition explicitly documented as not present at admission.
03
Conditions Diagnosed Prior to Admission
Assign "Y" for conditions that were diagnosed prior to admission (example: hypertension, diabetes mellitus, asthma).
04
Conditions Diagnosed During Admission
Assign "Y" for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred.
05
Outpatient Encounter Development
Assign Y for any condition that develops during an outpatient encounter prior to a written order for inpatient admission.
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Special Conditions
Special POA Assignment Scenarios
Chronic Condition with Acute Exacerbation
If a single code identifies both the chronic condition and the acute exacerbation, see POA guidelines pertaining to codes that contain multiple clinical concepts.
Possible, Probable, Suspected Diagnoses
If the final diagnosis was based on signs, symptoms or clinical findings suspected at the time of inpatient admission, assign "Y".
Impending or Threatened Conditions
If the diagnosis is based on symptoms or clinical findings that were present on admission, assign "Y".
Acute and Chronic Conditions
Assign "Y" for acute conditions present at time of admission and chronic conditions, even if not diagnosed until after admission.
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Complex Scenarios
Multiple Clinical Concepts and Conditions
Codes with Multiple Clinical Concepts
Assign "N" if at least one of the clinical concepts included in the code was not present on admission (e.g., COPD with acute exacerbation and the exacerbation was not present on admission).
Assign "Y" if all of the clinical concepts included in the code were present on admission (e.g., duodenal ulcer that perforates prior to admission).
Same Diagnosis Code for Multiple Conditions
Assign "Y" if all conditions represented by the single ICD-10-CM code were present on admission (e.g., bilateral unspecified age-related cataracts).
Assign "N" if any of the conditions represented by the single ICD-10-CM code was not present on admission.
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Specialised Conditions
Obstetrical, Perinatal, and Congenital Conditions
Obstetrical Conditions
Whether or not the patient delivers during the current hospitalisation does not affect assignment of the POA indicator. The determining factor is whether the pregnancy complication or obstetrical condition was present at the time of admission or not.
- Patient admitted in preterm labour: assign "Y"
- 2nd degree laceration during delivery: assign "N"
- Postpartum haemorrhage during hospitalisation: assign "N"
Perinatal Conditions
Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered present at admission and should be assigned "Y".
This includes conditions that occur during delivery (e.g., injury during delivery, meconium aspiration, exposure to streptococcus B in the vaginal canal).
Congenital Conditions and Anomalies
Assign "Y" for congenital conditions and anomalies except for categories Q00-Q99, Congenital anomalies, which are on the exempt list. Congenital conditions are always considered present on admission.
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External Causes
External Cause of Injury Codes
Assign "Y" for:
Any external cause code representing an external cause of morbidity that occurred prior to inpatient admission.
- Patient fell out of bed at home
- Patient fell out of bed in emergency room prior to admission
- Injury sustained before hospital arrival
Assign "N" for:
Any external cause code representing an external cause of morbidity that occurred during inpatient hospitalisation.
- Patient fell out of hospital bed during hospital stay
- Patient experienced an adverse reaction to a medication administered after inpatient admission
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Practical Examples
10 ICD-10-CM POA Indicator Scenario Examples
1
Diabetes Mellitus Type 2
Patient admitted with known history of Type 2 diabetes mellitus documented in medical records. POA Indicator: Y (condition diagnosed prior to admission)
2
Pneumonia with Culture Results
Patient admitted with pneumonia; culture results identifying Pseudomonas aeruginosa received three days after admission. POA Indicator: Y (infection present on admission even though organism identified later)
3
Hospital-Acquired Pressure Ulcer
Patient develops Stage 3 pressure ulcer on sacrum on day 5 of hospitalisation. POA Indicator: N (condition developed after admission)
4
COPD with Acute Exacerbation
Patient with known COPD admitted; develops acute exacerbation on day 2 of hospitalisation. POA Indicator: N (chronic condition present, but acute exacerbation not present on admission)
5
Bilateral Age-Related Cataracts
Patient admitted for cataract surgery; both cataracts documented as present. POA Indicator: Y (all conditions represented by the code were present on admission)
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POA Indicator Examples (Continued)
1
Preterm Labour
Patient admitted at 34 weeks gestation in active preterm labour. POA Indicator: Y (obstetrical condition present at time of admission)
2
Postpartum Haemorrhage
Patient delivers normally; experiences postpartum haemorrhage 6 hours after delivery during same hospitalisation. POA Indicator: N (condition developed after admission)
3
Newborn Meconium Aspiration
Newborn experiences meconium aspiration during delivery. POA Indicator: Y (condition occurred during delivery; considered present at admission for newborns)
4
Fall in Emergency Department
Patient falls in emergency department before admission order is written, sustaining hip fracture. POA Indicator: Y (condition developed during outpatient encounter prior to admission order)
5
Medication Adverse Reaction
Patient experiences allergic reaction to antibiotic administered 24 hours after inpatient admission. POA Indicator: N (external cause of morbidity occurred during hospitalisation)
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