Q75.4

See Section I.C.21. Factors influencing health status and contact with health services, Screening Appendix I Present on Admission Reporting Guidelines Introduction These guidelines are to be used as a supplement to the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837 Institutional). These guidelines are not intended to replace any guidelines in the main body of the ICD-10-CM Official Guidelines for Coding and Reporting. The POA guidelines are not intended to provide guidance on when a condition should be coded, but rather, how to apply the POA indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA indicator should then be assigned to those conditions that have been coded. As stated in the Introduction to the ICD-10-CM Official Guidelines for Coding and Reporting, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission or not. In the context of the official coding guidelines, the term “provider” means a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis. These guidelines are not a substitute for the provider’s clinical judgment as to the determination of whether a condition was/was not present on admission. The provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of findings. Please see the CDC website for the detailed list of ICD-10-CM codes that do not require the use of a POA indicator (https://www.cdc.gov/nchs/icd/icd-10-cm/files.html). The codes and categories on this exempt list are for circumstances regarding the healthcare encounter or factors influencing health status that do not represent a current disease or injury or that describe conditions that are always present on admission. General Reporting Requirements 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. Reporting Options Y – Yes N – No U – Unknown W – Clinically undetermined Unreported/Not used – (Exempt from POA reporting) Reporting Definitions Y = present at the time of inpatient admission N = not present at the time of inpatient admission U = documentation is insufficient to determine if condition is present on admission W = provider is unable to clinically determine whether condition was present on admission or not Timeframe for POA Identification and Documentation There is no required timeframe as to when a provider (per the definition of “provider” used in these guidelines) must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. In some cases, it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission. Determination of whether the condition was present on admission or not will be based on the applicable POA guideline as identified in this document, or on the provider’s best clinical judgment. If at the time of code assignment the documentation is unclear as to whether a condition was present on admission or not, it is appropriate to query the provider for clarification. Assigning the POA Indicator Condition is on the “Exempt from Reporting” list Leave the “present on admission” field blank if the condition is on the list of ICD- 10-CM codes for which this field is not applicable. This is the only circumstance in which the field may be left blank. POA Explicitly Documented Assign Y for any condition the provider explicitly documents as being present on admission. Assign N for any condition the provider explicitly documents as not present at the time of admission. Conditions diagnosed prior to inpatient admission Assign “Y” for conditions that were diagnosed prior to admission (example: hypertension, diabetes mellitus, asthma) Conditions diagnosed during the admission but clearly present before admission Assign “Y” for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred. Diagnoses subsequently confirmed after admission are considered present on admission if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis, or constitute an underlying cause of a symptom that is present at the time of admission. Condition develops during outpatient encounter prior to inpatient admission Assign Y for any condition that develops during an outpatient encounter prior to a written order for inpatient admission. Documentation does not indicate whether condition was present on admission Assign “U” when the medical record documentation is unclear as to whether the condition was present on admission. “U” should not be routinely assigned and used only in very limited circumstances. Coders are encouraged to query the providers when the documentation is unclear. Documentation states that it cannot be determined whether the condition was or was not present on admission Assign “W” when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was present on admission. Chronic condition with acute exacerbation during the admission If a single code identifies both the chronic condition and the acute exacerbation, see POA guidelines pertaining to codes that contain multiple clinical concepts. If a single code only identifies the chronic condition and not the acute exacerbation (e.g., acute exacerbation of chronic leukemia), assign “Y.” Conditions documented as possible, probable, suspected, or rule out at the time of discharge If the final diagnosis contains a possible, probable, suspected, or rule out diagnosis, and this diagnosis was based on signs, symptoms or clinical findings suspected at the time of inpatient admission, assign “Y.” If the final diagnosis contains a possible, probable, suspected, or rule out diagnosis, and this diagnosis was based on signs, symptoms or clinical findings that were not present on admission, assign “N”. Conditions documented as impending or threatened at the time of discharge If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were present on admission, assign “Y”. If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were not present on admission, assign “N”. Acute and Chronic Conditions Assign “Y” for acute conditions that are present at time of admission and N for acute conditions that are not present at time of admission. Assign “Y” for chronic conditions, even though the condition may not be diagnosed until after admission. If a single code identifies both an acute and chronic condition, see the POA guidelines for codes that contain multiple clinical concepts. Codes That Contain Multiple Clinical Concepts Assign “N” if at least one of the clinical concepts included in the code was not present on admission (e.g., COPD with acute exacerbation and the exacerbation was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission). Assign “Y” if all of the clinical concepts included in the code were present on admission (e.g., duodenal ulcer that perforates prior to admission). For infection codes that include the causal organism, assign “Y” if the infection (or signs of the infection) were present on admission, even though the culture results may not be known until after admission (e.g., patient is admitted with pneumonia and the provider documents Pseudomonas as the causal organism a few days later). Same Diagnosis Code for Two or More Conditions When the same ICD-10-CM diagnosis code applies to two or more conditions during the same encounter (e.g., two separate conditions classified to the same ICD-10-CM diagnosis code): Assign “Y” if all conditions represented by the single ICD-10-CM code were present on admission (e.g., bilateral unspecified age-related cataracts). Assign “N” if any of the conditions represented by the single ICD-10-CM code was not present on admission (e.g. traumatic secondary and recurrent hemorrhage and seroma is assigned to a single code T79.2, but only one of the conditions was present on admission). Obstetrical conditions Whether or not the patient delivers during the current hospitalization does not affect assignment of the POA indicator. The determining factor for POA assignment is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission or not. If the pregnancy complication or obstetrical condition was present on admission (e.g., patient admitted in preterm labor), assign “Y”. If the pregnancy complication or obstetrical condition was not present on admission (e.g., 2 degree laceration during delivery, postpartum hemorrhage that occurred during current hospitalization, fetal distress develops after admission), assign “N”. If the obstetrical code includes more than one diagnosis and any of the diagnoses identified by the code were not present on admission assign “N”. (e.g., Category O11, Pre-existing hypertension with pre-eclampsia) Perinatal conditions Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered present at admission and should be assigned “Y”. This includes conditions that occur during delivery (e.g., injury during delivery, meconium aspiration, exposure to streptococcus B in the vaginal canal). Congenital conditions and anomalies Assign “Y” for congenital conditions and anomalies except for categories Q00- Q99, Congenital anomalies, which are on the exempt list. Congenital conditions are always considered present on admission. External cause of injury codes Assign “Y” for any external cause code representing an external cause of morbidity that occurred prior to inpatient admission (e.g., patient fell out of bed at home, patient fell out of bed in emergency room prior to admission) Assign “N” for any external cause code representing an external cause of morbidity that occurred during inpatient hospitalization (e.g., patient fell out of hospital bed during hospital stay, patient experienced an adverse reaction to a medication administered after inpatient admission).