Present on Admission (POA) Reporting Accuracy: Five Years Later

on Tuesday, 11 December 2012. All News Items | Coding

Background

As part of the Deficit Reduction Act of 2005 (DRA), hospitals were required to begin reporting whether or not diagnoses were Present on Admission (POA) on or after October 1, 2007.

General POA Requirements:

  • POA indicator is required for all claims involving Medicare inpatients admitted to general IPPS acute care hospitals.
  • POA is 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 POA.
  • The POA indicator is assigned to the principal diagnosis and secondary diagnoses.
  • Inconsistent, missing, conflicting or unclear documentation must be resolved by the provider.
  • POA indicator is not reported if a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current Official Guidelines.
  • CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”

(Source: CMS POA Fact Sheet)

Office of Inspector General (OIG) November 23, 2012 Report: Assessment of Hospital Reporting of Present on Admission Indicators on Medicare Claims.OEI-06-09-00310

The OIG recently released a report that assessed POA indicator accuracy and the nature of any miscoding. As background to this review the OIG indicated that Section 5001 (c) of the Deficit Reduction Act of 2006 mandated that hospitals would not receive increased Medicare reimbursement for certain conditions that develop during a hospitals stay that were not present on admission. These conditions are referred to as “hospital-acquired conditions” and the list of conditions is updated annually. Assigning POA indicators “provides a necessary framework” for making the determination of whether or not a diagnosis is a “hospital-acquired condition.”

For the report, the OIG utilized contracted certified coders that reviewed medical records and “documented all misreported POA indicators and described circumstances that may have contributed to the errors.”

The OIG found that “hospital coders incorrectly reported 3 percent of the 5,491 POA indicators reviewed, resulting in the presence of at least one incorrect indicator on 129 claims (18 percent).” There were three main groups of errors identified and include:

  • Twenty-One Percent were related to the assessment of developing or chronic conditions
    • Conditions that were developing at the time of admission with misreported POA indicators included systemic inflammatory response syndrome (SIRS), septic shock, blood infections, urinary tract infections, pneumonia, pressure ulcers, constipation, and malnutrition.
    • Chronic conditions with misreported POA indicators included diabetes and patient’s experiencing an exacerbation of a chronic condition such as congestive heart failure.
  • Thirty-Two Percent involved errors in assigning POA indicators to exempted conditions.
    • In these cases the hospital coder either assigned a POA indicator code when he/she should have identified the diagnosis as exempt or coded a diagnosis as exempt when it was not on the published list of exemptions and should have been assigned POA indicators.
  • Forty-Seven Percent involved other reporting errors not associated with developing or chronic conditions or with exemptions. Specific examples in the report include:
    • The OIG coders found documentation contradicting the POA designation.
    • Medical record review clearly indicated the presence or absence of a diagnosis at the time of admission. “This suggests that hospital coders may have failed to notice or disregarded the information necessary to make an accurate POA assessment.”
    • Physician’s documentation not clearly indicating when a condition developed.
    • Other issues such as a diagnosis changing during the hospitalization.

 

The OIG concluded that the 3-percent error rate is relatively low and no recommendations were made. At MMP we believe that it is important to point out that in their conclusion, the OIG indicates that “POA indicators provide an opportunity for monitoring hospital quality of care and are critical to CMS’s efforts to link payment to quality, but they must be accurate to serve these purposes. Encouraging hospitals to assess POA reporting practices related to developing conditions and exemption codes, and to retrain staff as needed, could help to ensure accuracy.”

 

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM,CCDS, is the Director of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-two years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

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