These are the Present on Admission Frequently-asked Questions (POA FAQ's) that our members and others have forwarded to us.
As a part of this forum, as a service to our members and the inpatient discharge data community, NAHDO is forwarding the questions to the appropriate person with the expertise for a response. Donna Pickett, from CDCs National Center for Health Statistics (NCHS) and Sue Bowman, American Health Information Management Association (AHIMA) will review the responses of these FAQs to assure that the information provided is consistent with national guidelines and practices.
We invite all interested parties to post their questions to this forum.
We will take new issues and questions directly to the experts and incorporate the responses into the FAQ document. We expect this document to grow and evolve as the implementation of POA progresses.
NAHDO believes that having a central place for these implementation questions will benefit everyone.
So, PLEASE use this forum:
--post your questions (or email them directly to Robert Davis, NAHDO's National Standards Consultant (rdavis@nahdo.org)
--share your training materials and lessons learned
--discuss analytic and reporting issues.
Thanks for being a part of this forum!!
Q. What is AHIMA doing in regard to POA?
A. The NUBC stipulated that the four organizations that currently develop the Official ICD-9-CM Guidelines for Coding and Reporting should develop POA reporting guidelines to go along with the definitions (these four organizations are AHIMA, the American Hospital Association, CMS, and National Center for Health Statistics). So, I worked with these other three organizations to develop reporting guidelines. These guidelines were just released in October as a new section of the official ICD-9-CM guidelines. Here is the link to the new version of the ICD-9-CM guidelines – the POA reporting guidelines are at the end, in Appendix I (page 91):
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf States that already have, or will soon have, a POA reporting requirement have already begun to adopt our POA guidelines for their reporting requirement.
Sue Bowman, RHIA, CCS
Director, Coding Policy and Compliance
American Health Information Management Assocation
233 N. Michigan Avenue, Suite 2150
Chicago, IL 60601
Phone: (312) 233-1115
Email:
sue.bowman@ahima.org
Q. Will CMS require POA reporting on IP claims as of 10/1/07 as stated in previous communications?
A. Recent communications with representatives of the NUBC and CMS, indicate that there will be a delay in the implementation of POA reporting requirements from the originally announced October 1, 2007 date to January 1, 2008. Still unchanged is method of reporting POA on the HIPAA version (4010A1) of the 837 implementation guide using the K3 segment in the claim (2300) loop. It is still unknown if this delay will also cause a delay in changes to the Medicare grouper originally announced for implementation beginning for discharges on or after 10/1/2008. This response is based on an e-mail exchange between CMS and the NUBC. It is also unknown when the official CMS notification will occur. There has been communication with CMS requesting a prompt publication.
Qa. Does anyone know whether CMS is applying to POA requirements to Critical
Access Hospitals?
Qb. We were wondering the same - I am assuming yes as a reduction in payment for infection should apply to all -- however, they are not DRG based for reimbursement and this was under the inpatient PPS payment discussion.
A. NO
Q. What other states are implementing or planning to implement the on Present-On-Admission Indicator?
A. New York and California have been collection POA since the 1990’s.
The following states have indicated that they are planning to collect POA in the state reporting system in the near future.
• Texas
• Illinois
• Massachusetts
• Maine
• Wisconsin
• Pennsylvania
• New Jersey
• Florida
• Arizona
• Washington State
Q. What is Florida doing on Present-On-Admission?
A. I just received notice of Florida's AHCA proposed Inpatient Data Rule (59E-7.012, 59E-7.014 to modify inpatient data reporting requirements to incorporate POA.
http://ahca.myflorida.com/SCHS/chis_ruledev.shtml.
Florida will require POA for principal and up to 29 secondary diagnosis codes and 3 E-codes.
Q. What are the coding guidelines for POA?
A. Ginger Cox from OSHPD and I have highlighted and annotated the Coding Guidelines developed by NCHS for Present on Admission. Starting with this call we will be using this document to identify areas to share lessons learned. The NAHDO POA Work Group will be focusing on the education, collection, and use related to the successful implementation of the Present on Admission Indicator. This working document can be downloaded from the NAHDO web site at the following URL.
http://www.nahdo.org/documents/POA_Guidelines.pdf
Q. "After all the discussion and what I read so far still leads me to this question: Does the provider have to specifically assign or attest to the POA code for each diagnosis coded, or can the provider leave it to the coder's discretion to assign the code and only be involved if the coder queries the provider? I was hearing some of each, so I am wondering if this can be determined by each hospital independently. "
A. “My response to this question is that the NAHDO work group would serve as a liaison between CMS and health data organizations to identify priority issues, disseminated guidance, and share best practices. Sharing solutions across states and major stakeholders is a powerful tool in successfully implementing new things, like the POA indicator.
The reality is that physicians rarely provide nice neat lists of diagnoses or codes. Coders glean the documentation in the record after the patient is discharged, and collect the diagnoses too be coded from what is written in the notes and reports with supplemental details coming from the ancillary reports. The coders decide what gets coded, how it is coded and what order to report the codes. The coders will incorporate assigning the POA as part of the coding process. They will do their best with available documentation and guidelines to assign the POA to each code. Only if they have a question about a specific diagnosis will they query the provider for more information (and documentation). Physicians usually are not involved in the coding process for hospital patients, unless they are queried by the coder. Even then they usually do not see the codes that actually end up being billed and reported by the hospital for their patients.
Q. There was a question from one of the newly implementing states about an inpatient admission from one of the facility’s outpatient service areas. That inpatient record would be bundled by the billing system. There was concern whether the diagnosis codes carried from that outpatient visit would be carried forward without the appropriate coding of POA.
A. In responses to this question from both New York and California, the edits on both these systems would require the
hospital to have a POA indicator coded on all diagnosis codes reported to the state. It is recommended that other states implementing POA should also consider this edit to ensure that all reported diagnosis codes are coded with an associated POA indicator regardless the source of admission for the patient.
Q. Who are the Stakeholders? What is their role?
A. Stakeholders
• American Health Information Management Association (AHIMA) along with state health information management associations
• American Hospital Association
• State Hospital Associations
• Federal Agencies
• State Agencies
• American Medical Association
• Other health care specialist including nutritionists, audiologists, ect.
• Hospital Administrators including CEO's and CFO's
• Quality improvement organizations
• Infection Control personnel
• American Hospital Association
• AAHAM (American Association of Health Care Admihttp://www.aapc.com/nistrative Management
http://www.aaham.org/)
AAPC (American Academy of Professional Coders
http://www.aapc.com/)
• AAHAM members are often billing department directors who work with resolution of claims with errors. They are tasked with making sure all required data elements are present on claims. They would be good educators and able to share case studies. The same applies to the AAPC members who are physician and hospital coders
• I also believe nursing case management should be added to the stakeholders as well as utilization review professionals. If all payers will require POA it would make it necessary for case managers to communicate this data element to payers in addition to the current patient information.
• Information system vendors
Q. “There is some documentation issues I'd like to settle...slight differences in NUBC and the X12-837 Implementation Guides.... this one deals with the Present on Admission data element. In the UB04 it is called the "Present on Admission Indicator"- which is what we changed our SPARCS Data Dictionary to match a while ago In the X12-837 4050 Implementation Guide this data element is referred to as the "Onset of Diagnosis Indicator" - my question - is will this be
changing? Why does the X12-837 guide use this name?”
A. The original maintenance to the X12 standard to support THAT INDICATOR was done by me. At the time only NY and California used that data element so the name is what California and NY agreed which is the Onset of Diagnosis Indicator. Along the way many others have gotten interested in this data element and now Medicare will be adding it to its requirements as of 10/1/2007. When the NUBC agreed to add this element to the UB-04 a work group was formed to come up with reporting guidelines, which are now part of the UB-04 manual. At some point in that discussion there was consensus that the name of the element should change to Present on Admission, which is reflected in the UB-04 and X12 guides 5010 or later.
No matter what you call it, the data element is the same. It would probably be a good idea to transition SPARCS to using the new name. (If it was me for awhile I would puut both names with one in parenthesis in the SPARCS documentation.) The other harder change to transition to is that the NUBC work group came up with the values of Y, N, U, W and a meaning for a space. SPARCS and California just use Y, N, U. One would have to assume that most of the reporting should be Y or N, but the Medicare requirement of using the UB guidelines might prompt a more rapid move to the new acceptable code values.
Other potential questions:
- Coder responsibility versus Doctor Responsibility?
- Should we have multiple questions to address a variety of scenarios?
- POA assignment issues should be handled through the AHA Coding Clinic. Assigning POA will be part of coding, and the POA assigned will often depend on the code that is chosen.
- What is the process to provide input for the yearly changes to the Official ICD-9-CM coding guidelines related to the POA indicator?
- The guidelines should be maintained and updated by the Coding Maintenance Committee. Updates should be based on the questions and issues brought up by the coders as they gain experience trying to assign POAs. I also think regulators will have a say in the POA guidelines as they start to work with the data and see patterns and discrepancies, and start making decisions about how they want to use the data. I do not think anyone else can guess or foresee the types of issues the coders will have, or what the regulators will find.
- Coding issues resulting from patient’s being transferred from Hospital A to Hospital B.
- I foresee potential problems when there are patients transferred from hospital A to hospital B. I would like some additional guidance for Coders at hospital B when there are questions regarding if a patient came with the condition or if developed during this encounter. Physician at hospital B might not know all specifics from the previous encounter, and the discharge summary from hospital A as well may not be clear. A Coder will not be able to query a physician from another hospital; therefore, please make provisions/recommendations to proceed with this scenario.
- Physicans are required to do an admitting history and physical on all transferred patients. A transfer summary (and copy of ER records and other hospital documentation) also accompanies patients when they are transferred. I do not think these scenarios will be any harder for a coder to sort out then any other kind of patient.
- Need for further clarification on the definition of the U and W codes?
- Do we need examples?
The examples they will need is being able to determine when to use a U versus a W.
- Even though Medicare currently would not be requiring POA for Critical Access Hospitals (CAH’s) should be provide use cases when states would find this information necessary?
- Even though the guidelines are for Inpatient services, should be document states uses that fall outside the guidelines. (i.e. Massachusetts intent to collect on outpatient )
- Unresolved Coding Issues
- The coding guidelines state "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." The question is whether conditions caused by this outpatient encounter should be flagged in some way. In either case, should the coding guidelines be changed to clarify this situation.
- Is this also a case for POA being collected on outpatient encounters?