POA INDICATORS PART 2

Question 1

Chronic condition with acute exacerbation during the admission

If a single code identifies both the chronic condition and the acute exacerbation, see POA guidelines pertaining to codes that contain multiple clinical concepts.

If a single code only identifies the chronic condition and not the acute exacerbation (e.g., acute exacerbation of chronic leukemia), assign “____.”

Answer 1

Y

Question 2

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; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after 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).

Answer 2

Codes That Contain Multiple Clinical Concepts

Question 3

For infection codes that include the causal organism, assign “____” if the infection (or signs of the infection) were present on admission, even though the culture results may not be known until after admission (e.g., patient is admitted with pneumonia and the provider documents Pseudomonas as the causal organism a few days later).

Answer 3

Y

Question 4

Whether or not the patient delivers during the current hospitalization does not affect assignment of the POA indicator. The determining factor for POA assignment is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission or not.

If the pregnancy complication or obstetrical condition was present on admission (e.g., patient admitted in preterm labor), assign “Y”.

If the pregnancy complication or obstetrical condition was not present on admission (e.g., 2nd degree laceration during delivery, postpartum hemorrhage that occurred during current hospitalization, fetal distress develops after admission), assign “N”.

If the obstetrical code includes more than one diagnosis and any of the diagnoses identified by the code were not present on admission assign “N”. (e.g., Category O11, Pre-existing hypertension with pre-eclampsia)

Answer 4

Obstetrical conditions

Question 5

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).

Answer 5

Perinatal conditions