Present On Admission (POA) indicator list and reporting requirement


Present On Admission (POA) Indicators Scope Description:

Applies to Present On Admission (POA) Indicator requirement for all BlueCross BlueShield of TN lines of business.

Subject:  Present On Admission (POA) requirement Purpose:

To establish guidelines for Present On Admission (POA) Indicator requirement Standard:

POA indicators are needed when Acute Inpatient Prospective Payment System (IPPS) Hospital providers bill for selected Hospital Acquired Conditions (HACs), including some conditions on the National Quality Forum’s (NQF) list of Serious Reportable Events (commonly referred to as "Never Events"), these certain conditions have been selected according to the criteria in section 5001(c) of the Deficit Reduction Act (DRA) of 2005 and are reportable by The Centers for Medicare & Medicaid Services (CMS) POA Indicator Options:

· Y = Diagnosis was present at time of inpatient admission.

· N = Diagnosis was not present at time of inpatient admission.

· U = Documentation insufficient to determine if the condition  was present at the time of inpatient admission.

· W = Clinically undetermined. Provider unable to clinically  determine whether the condition was present at the time  of inpatient admission.

· 1 = Unreported/Not used. Exempt from POA reporting. This  code is equivalent to a blank on the UB-04, therefore;  for paper claims, in this instance, leave the space blank  and a “1” will automatically be assigned


Present On Admission (POA) Indicators

 Claims will be rejected if:

 · POA “1” is submitted on a paper UB04 inpatient claim
 · POA equal space is submitted on an electronic inpatient claim
 · POA is required but not submitted

BlueCross BlueShield of Tennessee (BCBST) began accepting POA indicator codes on inpatient hospital claims effective January 1, 2008.


Note: BlueAdvantage lines of business will follow CMS Billing Guidelines.

Present On Admission (POA) Indicator


Note: This article was updated on June 5, 2013, to reflect current Web addresses. This article was previously revised on September 11, 2007, to clarify the timeframes for reporting the POA indicators. All other information remains unchanged.



Background

Section 5001(c) of the Deficit Reduction Act of 2005 requires hospitals to begin reporting the secondary diagnoses that are present on admission (POA) of patients effective for discharges on or after October 1, 2007. By October 1, 2007, the Centers for Medicare & Medicaid Services (CMS) will have selected at least 2 high cost or high volume (or both) diagnosis codes that:

• Represent conditions (including certain hospital acquired infections) that could reasonably have been prevented through the application of evidence-based guidelines; and

• When present on a claim along with other (secondary) diagnoses, have a DRG assignment with a higher payment weight. Then, for acute care inpatient PPS discharges on or after October 1, 2008, while the presence of these diagnosis codes on claims could allow the assignment of a higher paying DRG, when they are present at the time of discharge, but not at the time of admission, the DRG that must be assigned to the claim will be the one that does not result in the higher payment.

Beginning for discharges on or after October 1, 2007, hospitals should begin reporting the POA code for acute care inpatient PPS discharges. There is one exception, i.e., claims submitted via direct data entry (DDE) should not report the POA codes until January 1, 2008, as the DDE screens will not be able to accommodate the codes until that date.

Between October 1, 2007, and December 31, 2007, CMS will collect the information on the hospital claim, but does not intend to provide any remittance or other information to hospitals if the information is not submitted correctly for each diagnosis on the claim. Hospitals that fail to provide the POA code for discharges on or after January 1, 2008 will receive a remittance advice remark code informingthem that they failed to report a valid POA code. However, beginning with discharges on or after April 1, 2008, Medicare will return claims to the hospital if the POA code is not reported and the hospital will have to supply the correct POA code and resubmit the claim. In order to be able to group these diagnoses into the proper DRG, CMS needs to capture a Present On Admission (POA) indicator for all claims involving inpatient admissions to general acute care hospitals. CR 5499, from which this article is taken, announces this requirement and provides your fiscal intermediaries (FI) and A/B MACs with the coding and editing requirements, and software modifications needed to successfully implement this indicator. Note: Adjustments to the relative weight that occur because of this action are not budget neutral. Specifically, aggregate payments for discharges in a fiscal year could be changed as a result of these adjustments.

These POA guidelines are not intended to replace any found in the ICD-9-CM Official Guidelines for Coding and Reporting, nor are they intended to provide guidance on when a condition should be coded. Rather, you should use them in conjunction with the UB-04 Data Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each “principal” diagnosis and “other” diagnoses codes reported on claim forms (UB-04 and 837 Institutional). Information regarding the UB-04 Data Specifications may be found at http://www.nubc.org/become.html on the Internet.

Note: Critical access hospitals, Maryland waiver hospitals, long term care hospitals, cancer hospitals, and children’s inpatient facilities are exempt from this requirement.

The following information, from the UB-04 Data Specifications Manual, is provided to help you understand how and when to code POA indicators:

1. General Reporting Requirements

• Pertain to all claims involving inpatient admissions to general acute care  hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information.

• Present on admission is defined as present at the time the order for inpatient admission occurs -- conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.
• POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.
• Issues related to inconsistent, missing, conflicting, or unclear documentation must still be resolved by the provider. • If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported.
• CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”
2. Reporting Options and Definitions
• Y - Yes (present at the time of inpatient admission)
• N – No (not present at the time of inpatient admission)
• U - Unknown (documentation is insufficient to determine if condition is present at time of inpatient admission)
• W – Clinically undetermined (provider is unable to clinically determine whether condition was present at time of inpatient admission or not)
• 1 -- Unreported/Not used – Exempt from POA reporting (This code is the equivalent of a blank on the UB-04, but blanks are not desirable when submitting data via the 4010A1.

The POA data element on your electronic claims must contain the letters “POA”, followed by a single POA indicator for every diagnosis that you report. The POA indicator for the principal diagnosis should be the first indicator after “POA,” and (when applicable) the POA indicators for secondary diagnoses would follow. The last POA indicator must be followed by the letter “Z” to indicate the end of the data element (or FIs and A/B MACs will allow the letter “X” which CMS may use to identify special data processing situations in the future). Note that on paper claims the POA is the eighth digit of the Principal Diagnosis field (FL 67), and the eighth digit of each of the secondary diagnosis fields (FL 67 A-Q); and on claims submitted electronically via 837, 4010 format, you must use segment K3 in the 2300 loop, data element K301.

Below is an example of what this coding should look like on an electronic claim:

If segment K3 read as follows: “POAYNUW1YZ,” it would represent the POA indicators for a claim with 1 principal and 5 secondary diagnoses. The principal diagnosis was POA (Y), the first secondary diagnosis was not POA (N), it was unknown if the second secondary diagnosis was POA (U), it is clinically undetermined if the third secondary diagnosis was POA (W), the fourth secondary diagnosis was exempt from reporting for POA (1), and the fifth secondary diagnosis was POA (Y). As of January 1, 2008, all direct data entry (DDE) screens will allow for the entry of POA data and POA data will also be included with any secondary claims sent by Medicare for coordination of benefits purposes.

See the complete instructions in the UB-04 Data Specifications Manual for more specific instructions and examples.

Note: CMS, in consultation with the Centers for Disease Control and Prevention and other appropriate entities, may revise the list of selected diagnose from time to time, but there will always be at least two conditions selected for discharges occurring during any fiscal year. Further, this list of diagnosis codes and DRGs is not subject to judicial review.

Finally, you should keep in mind that achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures requires a joint effort between the healthcare provider and the coder. Medical record documentation from any provider (a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis) involved in the patient’s care and treatment may be used to support the determination of whether a condition was present on admission or not; and the importance of consistent, complete documentation in the medical record cannot be overemphasized.

NOTE: You, your billing office, third party billing agents and anyone else involved in the transmission of this data must insure that any resequencing of diagnoses codes prior to their transmission to CMS, also includes a resequencing of the POA indicators.


Present on Admission (POA) Indicators

Required by Blue Cross and Blue Shield of Kansas

Effective with inpatient discharges as of April 1, 2007 and after, BCBSKS requires all hospital providers to appropriately code POA indicators as part of their inpatient claim and record.

This BCBSKS requirement:
• Applies to all inpatient discharges of April 1, 2007 or after.
• Required for all contracting and non-contracting hospital providers.
• Required for all hospitals including critical access hospitals etc. that may be exempt from this requirement by other payers such as Medicare.
• Does not apply if Medicare is the primary payer.
• Applies to inpatient claims when another insurance company (excluding Medicare) is the primary payer. BCBSKS will require POA information on inpatient claims even if the primary payer did not require the information.

Present on admission is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery are considered as present on admission. POA indicators are assigned to principal and secondary diagnoses and the external cause of injury codes.

The reporting options for all diagnosis reporting are as follows:

CODE DEFINITION
Y Yes – Present at time of admission
N No – Not Present at time of inpatient admission
U No information on record – insufficient documentation
W Clinically Undetermined – Provider is unable to determine whether or not diagnosis was Present upon Admission

Blank Exempt from POA Reporting
* (effective 7/1/11) Exempt from POA Reporting
* UB-04 only; not for use on 837

The following pages list all diagnosis codes that are exempt from POA reporting and do not require a POA indicator effective October 1, 2013. This list is updated every October by the National Uniform Billing Committee (NUBC).


 ICD-9DIAGNOSIS ICD-9 NOMENCLATURE POA EXEMPT

E0000 CIVILIAN ACTIVITY DONE FOR INCOME OR PAY Y
E0001 MILITARY ACTIVITY Y
E0002 VOLUNTEER ACTIVITY Y
E0008 OTHER EXTERNAL CAUSE STATUS Y
E0009 UNSPECIFIED EXTERNAL CAUSE STATUS Y
E0010 ACTIVITIES INVOLVING WALKING, MARCHING AND HIKING Y
E0011 ACTIVITIES INVOLVING RUNNING Y
E0020 ACTIVITIES INVOLVING SWIMMING Y
E0021 ACTIVITIES INVOLVING SPRINGBOARD AND PLATFORM DIVING Y
E0022 ACTIVITIES INVOLVING WATER POLO Y
E0023 ACTIVITIES INVOLVING WATER AEROBICS AND WATER EXERCISE Y
E0024 ACTIVITIES INVOLVING UNDERWATER DIVING AND SNORKELING Y
E0025 ACTIVITIES INVOLVING ROWING, CANOEING, KAYAKING, RAFTING AND TUBING Y
E0026 ACTIVITIES INVOLVING WATER SKIING AND WAKE BOARDING Y
E0027 ACTIVITIES INVOLVING SURFING, WINDSURFING AND BOOGIE BOARDING Y
E0028 ACTIVITIES INVOLVING WATER SLIDING Y
E0029 OTHER ACTIVITY INVOLVING WATER AND WATERCRAFT Y
E0030 ACTIVITIES INVOLVING ICE SKATING Y
E0031 ACTIVITIES INVOLVING ICE HOCKEY Y
E0032 ACTIVITIES INVOLV SNOW (ALPINE) (DOWNHILL) SKIING, SNOW BOARDING, SLEDDING, ETC. Y
E0033 ACTIVITIES INVOLVING CROSS COUNTRY SKIING Y
E0039 OTHER ACTIVITY INVOLVING ICE AND SNOW Y
E0040 ACTIVITIES INVOLVING MOUNTAIN CLIMBING, ROCK CLIMBING AND WALL CLIMBING Y
E0041 ACTIVITIES INVOLVING RAPPELLING Y
E0042 ACTIVITIES INVOLVING BASE JUMPING Y
E0043 ACTIVITIES INVOLVING BUNGEE JUMPING Y
E0044 ACTIVITIES INVOLVING HANG GLIDING Y
E0049 OTHER ACTIVITY INVOLVING CLIMBING, RAPPELLING AND JUMPING OFF Y
E0050 ACTIVITIES INVOLVING DANCING Y
E0051 ACTIVITIES INVOLVING YOGA Y
E0052 ACTIVITIES INVOLVING GYMNASTICS Y
E0053 ACTIVITIES INVOLVING TRAMPOLINE Y
E0054 ACTIVITIES INVOLVING CHEERLEADING Y
E0059 OTHER ACTIVITY INVOLVING DANCING AND OTHER RHYTHMIC MOVEMENTS

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