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March 27, 2018

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Starting April 1, Claims Missing POA Indicators Will Be Returned

April 8, 2008:
Are you correctly reporting the present-on-admission (POA) indicator for all diagnoses on claims for inpatient visits? It matters because effective April 1, 2008, if the POA indicators are missing, Medicare will return the claim and delay payment.

The POA indicator is a new reporting requirement for all diagnoses on inpatient visits submitted to Medicare. All claims for inpatient admissions to acute care hospitals and other facilities are subject to the regulation mandating reporting of POA information.

POA Reporting Options and Definitions
Y = YesPresent at the time of inpatient admission
N = NoNot present at the time of inpatient admission
U = UnknownThe documentation is insufficient to determine if the condition was present at the time of inpatient admission
W = Clinically UndeterminedThe provider is unable to clinically determine whether the condition was present at the time of inpatient admission
1 = Unreported/Not usedExempt from POA reporting (e.g., normal delivery)

The POA indicator is the first step of many the Centers for Medicare and Medicaid Services is taking to link quality and reimbursement. The POA indicator establishes when a condition occurred—whether the condition was present on admission or whether it developed after admission and before discharge. A condition is considered POA if it is present at the time of the order for inpatient admission. Conditions that develop during an outpatient encounter (e.g., an emergency department visit or outpatient surgery) are considered as present on admission.

Section 5001(a) of the Deficit Reduction Act mandated the new reporting requirement for hospitals submitting claims to Medicare. The POA indicator was required for all hospital inpatient Medicare claims beginning October 1, 2007. Hospitals under the inpatient prospective payment system (IPPS) have been reporting a POA indicator for all principal and secondary diagnosis codes on their inpatient claims since January 1, 2008. Since then, claims submitted without the POA indicators have continued to be processed and paid, but the remittance advice indicates a claim submission error. Beginning April 1, 2008, claims submitted without POA indicators will be returned to provider (RTP) for correction. Once the errors are corrected, the claims will be processed as usual; however, if the POA indicator errors are not corrected, the claims will remain suspended until CMS provides the contractors with further instructions regarding processing these claims. Because infections acquired in the hospital can significantly increase the DRG rate, the POA indicator will also affect reimbursement after October 1, 2008, when the MS-DRG grouper will use the indicator in MS-DRG assignment.

The ICD-9-CM coding guidelines were revised effective November 15, 2007, to include the new POA indicator and the list of codes exempt from POA indicator reporting requirements. The guidelines can be found at: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf. The Centers for Disease Control (CDC) publishes diagnostic criteria that may also help coders determine whether a condition is nosocomial (originates or occurs in a hospital) on its website at: http://www.cdc.gov/ncidod/dhqp/pdf/nnis/NosInfDefinitions.pdf.

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical/Technical Editor


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