CCDS POA and Hospital-Acquired Conditions (HACs) 4

Question 1

A patient is admitted with a stage 2 pressure injury on the coccyx that was documented as present on admission. Two days later, nursing documents a new stage 2 pressure injury on the right heel. What is the correct POA indicator for the heel pressure injury?

Accepted Answer

N – not present on admission

Answer

The right heel pressure injury developed after admission, making it not present on admission (N), which may trigger HAC payment implications.

Question 2

Which of the following CMS-designated HACs requires a POA indicator of 'N' to affect MS-DRG payment?

Accepted Answer

Catheter-associated urinary tract infection (CAUTI)

Answer

CAUTI is a CMS-designated HAC, and when the POA indicator is 'N', it triggers the HAC payment adjustment.

Question 3

A physician documents 'possible aspiration pneumonia' in the H&P but does not confirm or deny it was present on admission. What POA indicator should be assigned?

Accepted Answer

U

Answer

When documentation is insufficient to determine whether a condition was present on admission, the POA indicator 'U' (unknown) is assigned.

Question 4

Under the HAC Reduction Program, hospitals in the worst-performing quartile for HAC rates receive what penalty?

Accepted Answer

1% reduction in total Medicare payments

Answer

The ACA established a 1% reduction in total Medicare payments for hospitals in the worst-performing quartile under the HAC Reduction Program.

Question 5

A patient presents to the ED with left knee pain and is admitted. During the admission workup, an MRI reveals an occult fracture of the left femoral neck that was not previously diagnosed. What POA indicator applies?

Accepted Answer

Y – condition existed before admission

Answer

A condition that existed prior to admission, even if undiagnosed, is still considered present on admission and receives a POA indicator of 'Y'.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS POA and Hospital-Acquired Conditions (HACs) 4