CIC Present on Admission (POA) Indicators and Reporting 3

Question 1

When querying a physician to clarify POA status, what must the query include to remain compliant?

Accepted Answer

Clinical indicators from the medical record that prompted the need for clarification

Answer

A suggested POA indicator to ensure documentation supports the preferred DRG

Answer

A statement of the expected reimbursement impact of each possible response

Answer

Instructions to change the diagnosis to avoid a HAC designation

Question 2

A patient is transferred from a skilled nursing facility with a Stage 2 pressure ulcer on the sacrum, documented as present prior to transfer. What POA indicator applies?

Accepted Answer

Y — present at the time of inpatient admission

Answer

N — it was not present at this hospital

Answer

U — insufficient documentation

Answer

W — clinically undetermined

Question 3

Which of the following best defines 'Present on Admission' for ICD-10-CM coding purposes?

Accepted Answer

A condition present at the time of the order for inpatient admission

Answer

Any condition documented within the first 24 hours of the hospital stay

Answer

Only conditions listed on the admitting physician's history and physical

Answer

Conditions identified at the patient's most recent prior inpatient admission

Question 4

A patient with documented atrial fibrillation is admitted for elective cardioversion. What POA indicator applies to the atrial fibrillation?

Accepted Answer

Y — present at the time of the inpatient admission order

Answer

N — the condition will be treated and may resolve during the stay

Answer

U — unknown, because the condition may change with treatment

Answer

W — clinically undetermined

Question 5

Which organization publishes the official POA indicator reporting guidelines used by inpatient coders in the United States?

Accepted Answer

The Centers for Medicare & Medicaid Services (CMS)

Answer

The American Hospital Association (AHA) Coding Clinic editorial board

Answer

The American Health Information Management Association (AHIMA)

Answer

The Joint Commission

Question 6

A patient develops a deep vein thrombosis (DVT) on post-operative day 4, confirmed not to be present at admission. What is the most appropriate coding action?

Accepted Answer

Assign POA indicator N and code the DVT, noting the potential HAC impact on reimbursement

Answer

Assign POA indicator Y to ensure the full DRG payment is received

Answer

Omit the DVT code entirely to avoid a reduction in DRG payment

Answer

Query the physician to reclassify the DVT as a pre-existing condition

Question 7

Which condition would most appropriately receive a POA indicator of 'W'?

Accepted Answer

A pressure ulcer whose depth and staging could not be clinically determined at the time of admission

Answer

Pneumonia documented as the principal diagnosis in the admission history and physical

Answer

A catheter-associated UTI diagnosed 5 days after admission

Answer

Hypertension the patient has been treated for over the past 10 years