The Present on Admission (POA) indicator is a classification system used in medical coding to identify whether a patient’s diagnosis was present when they were officially admitted to an inpatient hospital setting. This code is applied to every diagnosis on a claim form, separating conditions the patient arrived with from those that developed during the hospital stay. The POA indicator serves as a crucial mechanism for tracking the quality of patient care and ensuring the accuracy of medical records. It provides regulatory bodies with data necessary to distinguish between pre-existing conditions and potential complications of treatment.
Defining the Present on Admission (POA) Concept
The POA indicator is rooted in regulatory efforts by the Centers for Medicare & Medicaid Services (CMS) to improve healthcare quality and accountability. It was introduced following the Deficit Reduction Act of 2005, which aimed to curb payments for preventable complications that occur during a hospitalization. This system requires hospitals to report all secondary diagnoses and specify their POA status, creating a clear distinction between conditions acquired in the community and those acquired in the facility. The mandate for reporting POA indicators for Medicare discharges began in 2007, marking a significant shift toward linking payment to quality of care.
The definition of “present on admission” means the condition existed at the time the order for inpatient admission was written. Conditions that arise during an outpatient encounter, such as in the emergency department or during observation, are included within the POA definition. This reporting requirement applies to all inpatient claims submitted to CMS for general acute care hospitals.
Decoding the POA Indicator Values
A limited set of single-character codes is used to specify the POA status for each diagnosis documented in the patient’s medical record.
- ‘Y’ signifies that the diagnosis was definitely present at the time of the patient’s inpatient admission (e.g., a patient admitted for a fractured hip that occurred at home).
- ‘N’ means the condition was not present at the time of admission, indicating it developed after the patient was officially admitted. This ‘N’ designation flags a potential Hospital-Acquired Condition.
- ‘U’ is used when the medical documentation is insufficient to determine whether the condition was present upon arrival.
- ‘W’ is assigned when the provider is unable to clinically determine if the condition was POA, even with complete documentation.
- ‘1’ means the diagnosis is exempt from POA reporting, typically because the condition is one for which POA status is not applicable, such as certain congenital conditions or external cause of injury codes.
These standardized values ensure that all hospitals and payers interpret a patient’s diagnosis history uniformly for payment and quality reporting purposes.
How POA Status Affects Hospital Payment
The POA indicator affects how hospitals are reimbursed, particularly under the Medicare Inpatient Prospective Payment System (IPPS). Hospital payment is largely determined by the patient’s Medicare Severity Diagnosis Related Group (MS-DRG), which groups similar patient cases with comparable resource consumption. Secondary diagnoses that are coded as a Complication or Comorbidity (CC) or a Major Complication or Comorbidity (MCC) can often shift a case to a higher-paying MS-DRG.
If a patient develops a condition identified on the Hospital-Acquired Conditions (HAC) list, and that condition is coded with an ‘N’ (Not Present on Admission), the hospital will not receive the higher MS-DRG payment associated with that secondary diagnosis. The case is instead paid as if the secondary diagnosis was not present, effectively penalizing the facility for a preventable or acquired condition. This payment adjustment is designed to incentivize hospitals to improve patient safety and reduce the occurrence of conditions like certain infections or pressure ulcers.
Additionally, a diagnosis coded as ‘U’ (Unknown) is treated the same as an ‘N’ for the purpose of HAC payment adjustment, resulting in a non-payment for the higher-paying MS-DRG. The only HAC-listed conditions that receive the full payment are those coded as ‘Y’ or ‘W’ (Clinically Undetermined), recognizing that the condition was either present on arrival or could not be determined clinically by the provider. This linkage between POA status and MS-DRG payment structure is a regulatory mechanism to promote better quality of care.
The Role of Clinical Documentation
The accuracy of the POA indicator depends on the quality and specificity of the medical record documentation provided by clinicians. Coders, who are responsible for assigning the POA indicator, must rely on the documentation available at the time of coding to make their determination. If a physician fails to clearly document the onset or presence of a condition upon admission, the coder may be forced to use the ‘U’ (Unknown) indicator, which can trigger a payment reduction if the condition is on the HAC list.
This process necessitates close collaboration between healthcare providers and coding professionals. Clinicians must be meticulous in recording the circumstances of a patient’s illness, specifically noting whether a condition was observed or diagnosed upon arrival or if it developed later in the stay. When documentation is ambiguous, the coder must often query the physician to clarify the POA status, a step that helps ensure both accurate reimbursement and correct quality metric reporting.