CCDS POA and Hospital-Acquired Conditions (HACs) 2

Question 1

Which POA indicator is assigned when documentation is insufficient to determine if the condition was present at the time of inpatient admission?

Accepted Answer

U - Documentation is insufficient to determine POA status

Answer

The 'U' indicator is assigned when the medical record documentation does not have sufficient information to determine whether the condition was present at admission.

Question 2

Under the HAC payment adjustment, which of the following conditions would trigger a payment reduction if NOT documented as present on admission?

Accepted Answer

Central line-associated bloodstream infection (CLABSI)

Answer

CLABSI is one of CMS's designated HACs. When CLABSI develops during the hospitalization and is not documented as POA=Y, CMS will not pay the additional costs associated with treating that complication.

Question 3

A patient is admitted through the ED with a stage II pressure ulcer documented in the triage nursing note. The admitting physician's H&P does not mention the pressure ulcer. What is the correct POA indicator?

Accepted Answer

Y - Present at admission, since the nursing note documents it at time of triage

Answer

A condition documented in any part of the medical record at the time of admission including nursing assessments during triage can be assigned POA=Y.

Question 4

Which diagnosis has a POA indicator exempt status and does not require POA reporting?

Accepted Answer

External cause codes (V, W, X, Y codes) for injuries

Answer

External cause codes (ICD-10-CM V, W, X, Y codes) are exempt from POA reporting requirements. These codes describe circumstances of injury such as falls or motor vehicle accidents.

Question 5

A patient with documented stage III pressure ulcer on the coccyx at admission progresses to stage IV during the hospitalization. How should the POA and final pressure ulcer stage be coded?

Accepted Answer

Code stage IV with POA=Y since the ulcer was present at admission regardless of progression

Answer

When a pressure ulcer is present on admission at a lower stage and worsens during the hospitalization, the highest stage documented during the stay is coded with POA=Y.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS POA and Hospital-Acquired Conditions (HACs) 2