POA INDICATORS PART 1

Question 1

Defined as present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

____ indicator is assigned to principal and secondary diagnoses and the external cause of injury codes.

Answer 1

Present on Admission

Question 2

What is the indicator for present at the time of inpatient admission?

Answer 2

Y-yes

Question 3

What is the indicator for not present at the time of inpatient admission?

Answer 3

N-no

Question 4

What is the indicator for when documentation is insufficient to determine if condition is present on admission?

Answer 4

U-unknown

Question 5

What is the indicator for when a provider is unable to clinically determine whether condition was present on admission or not?

Answer 5

W-clinically undetermined

Question 6

Condition is on the “_________________” list 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. This is the only circumstance in which the field may be left blank.

Answer 6

Exempt from Reporting

Question 7

Conditions diagnosed prior to inpatient admission

Assign “____” for conditions that were diagnosed prior to admission (example: hypertension, diabetes mellitus, asthma)

Conditions diagnosed during the admission but clearly present before admission

Assign “____” 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.

Answer 7

Y

Question 8

Documentation does not indicate whether condition was present on admission

Assign “___” when the medical record documentation is unclear as to whether the condition was present on admission. “___” should not be routinely assigned and used only in very limited circumstances.

Answer 8

U

Question 9

What indicator encourages coders to query the providers when the documentation is unclear?

Answer 9

U

Question 10

Documentation states that it cannot be determined whether the condition was or was not present on admission

Assign “____” when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was present on admission.

Answer 10

W