FREE CCDS POA and Hospital-Acquired Conditions (HACs) Questions and Answers

Question 1

A patient develops a catheter-associated urinary tract infection (CAUTI) on the third day of their hospital stay. What is the correct Present on Admission (POA) indicator for this diagnosis?

Accepted Answer

N (No, not present on admission)

Answer

The POA indicator 'N' signifies that the condition was not present at the time of inpatient admission. Since the CAUTI developed after admission, 'N' is the correct indicator.

Question 2

Which of the following conditions is on the CMS list of Hospital-Acquired Conditions (HACs) that can lead to a payment reduction if not POA?

Accepted Answer

Falls and trauma (e.g., fracture) acquired during the stay

Answer

The CMS HAC list includes specific, preventable conditions. A fall and trauma, such as a fracture or dislocation, that occurs after admission is a listed HAC, as are Stage 3 and 4 pressure ulcers and certain surgical site infections.

Question 3

What is the financial impact to a hospital if a patient acquires a Stage 3 pressure ulcer (a HAC) during their stay?

Accepted Answer

The DRG is paid as if the HAC was not present.

Answer

Under the HAC Reduction Program, if a condition on the HAC list is acquired during the stay (POA = N or U), the DRG is recalculated for payment as if that secondary diagnosis were not present. This typically results in assignment to a lower-weighted and lower-paying DRG.

Question 4

A patient is admitted from the emergency department with sepsis. The admission note does not mention acute kidney injury (AKI), but labs drawn in the ED show an elevated creatinine. AKI is first diagnosed on day 2. What is the likely POA status of the AKI?

Accepted Answer

Y (Yes)

Answer

The POA indicator applies to conditions present at the time of the inpatient admission order. Since the clinical indicators (elevated creatinine) were present from the ED visit immediately preceding admission, the AKI was present on admission, even though it was not diagnosed until later. The correct POA is 'Y'.

Question 5

When is it appropriate for a coder to assign the POA indicator 'U' (Unknown)?

Accepted Answer

When the documentation is insufficient to make a determination.

Answer

The 'U' indicator should be used as a last resort when the medical record documentation is insufficient to determine if the condition was present at the time of admission. This indicates a documentation gap that could not be clarified.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

FREE CCDS POA and Hospital-Acquired Conditions (HACs) Questions and Answers