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 compliant query must be non-leading and based on clinical indicators found in the documentation, without suggesting a preferred answer or referencing reimbursement impact.

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

Since the pressure ulcer was documented as present before the inpatient admission order, POA indicator 'Y' is assigned.

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

POA is officially defined as a condition present at the time of the order for inpatient admission, including conditions that developed during an outpatient encounter resulting in the 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

Atrial fibrillation was clearly the reason for admission and was present before the admission order was placed, making POA indicator 'Y' correct.

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

CMS publishes the official POA reporting guidelines as part of the inpatient prospective payment system final rule and related transmittals.

CIC - Certified Inpatient Coder Practice Test

CIC - Certified Inpatient Coder Practice Test

CIC Present on Admission (POA) Indicators and Reporting 3