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).
T79.2
Traumatic secondary and recurrent hemorrhage and seroma
Exclusions 6 never code together
Excludes2 — not included here, but the patient may have both. Code both when documented.
7th character 3
Instructional notes 3
- Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code
- The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes.
- code to identify any retained foreign body, if applicable (Z18.-)Z18.-
Official Guidelines 24 names this code
ICD-10-CM Official Guidelines for Coding and Reporting, quoted in full. Published by CMS and NCHS; in the public domain.
Most categories in chapter 19 have a 7 character requirement for each applicable code. Most categories in this chapter have three 7 character values (with the exception of fractures): A, initial encounter, D, subsequent encounter and S, sequela. Categories for traumatic fractures have additional 7 character values. While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7 character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem. For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device, implant or graft that was placed at a previous encounter. 7 character “A”, initial encounter is used for each encounter where the patient is receiving active treatment for the condition. 7 character “D” subsequent encounter is used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7 characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7 character “D” (subsequent encounter). 7 character “S”, sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7 character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7 character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code. See Section I.B.10. Sequelae, (Late Effects)
When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Codes from category T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. Traumatic injury codes (S00- T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds. The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.
Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.
When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15). When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.
Injury codes from Chapter 19 should not be assigned for injuries that occur during, or as a result of, a medical intervention. Assign the appropriate complication code(s).
The principles of multiple coding of injuries should be followed in coding fractures. Fractures of specified sites are coded individually by site in accordance with both the provisions within categories S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92 and the level of detail furnished by medical record content. A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced. More specific guidelines are as follows:
Traumatic fractures are coded using the appropriate 7 character for initial encounter (A, B, C) for each encounter where the patient is receiving active treatment for the fracture. The appropriate 7 character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion. Fractures are coded using the appropriate 7 character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes. Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7 character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R). Malunion/nonunion: The appropriate 7 character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion. The open fracture designations in the assignment of the 7th character for fractures of the forearm, femur and lower leg, including ankle are based on the Gustilo open fracture classification. When the Gustilo classification type is not specified for an open fracture, the 7th character for open fracture type I or II should be assigned (B, E, H, M, Q). A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. See Section I.C.13. Osteoporosis. The aftercare Z codes should not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7 character.
Multiple fractures are sequenced in accordance with the severity of the fracture.
For physeal fractures, assign only the code identifying the type of physeal fracture. Do not assign a separate code to identify the specific bone that is fractured.
The ICD-10-CM makes a distinction between burns and corrosions. The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance. The burn codes are also for burns resulting from electricity and radiation. Corrosions are burns due to chemicals. The guidelines are the same for burns and corrosions. Current burns (T20-T25) are classified by depth, extent and by agent (X code). Burns are classified by depth as first degree (erythema), second degree (blistering), and third degree (full-thickness involvement). Burns of the eye and internal organs (T26-T28) are classified by site, but not by degree.
Sequence first the code that reflects the highest degree of burn when more than one burn is present. a. When the reason for the admission or encounter is for treatment of external multiple burns, sequence first the code that reflects the burn of the highest degree. b. When a patient has both internal and external burns, the circumstances of admission govern the selection of the principal diagnosis or first-listed diagnosis. c. When a patient is admitted for burn injuries and other related conditions such as smoke inhalation and/or respiratory failure, the circumstances of admission govern the selection of the principal or first-listed diagnosis.
Classify burns of the same anatomic site and on the same side but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-).
Non-healing burns are coded as acute burns. Necrosis of burned skin should be coded as a non-healed burn.
For any documented infected burn site, use an additional code for the infection.
When coding burns, assign separate codes for each burn site. Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used. Codes for burns of "multiple sites" should only be assigned when the medical record documentation does not specify the individual sites.
surface involved Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, for acute burns or corrosions when the site of the burn or corrosion is not specified or when there is a need for additional data. It is advisable to use category T31 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units. It is also advisable to use category T31 as an additional code for reporting purposes when there is mention of a third- degree burn involving 20 percent or more of the body surface. Codes from categories T31 and T32 should not be used for sequelae of burns or corrosions. Categories T31 and T32 are based on the classic “rule of nines” in estimating body surface involved: head and neck are assigned nine percent, each arm nine percent, each leg 18 percent, the anterior trunk 18 percent, posterior trunk 18 percent, and genitalia one percent. Providers may change these percentage assignments where necessary to accommodate infants and children who have proportionately larger heads than adults, and patients who have large buttocks, thighs, or abdomen that involve burns.
Encounters for the treatment of the late effects of burns or corrosions (i.e., scars or joint contractures) should be coded with a burn or corrosion code with the 7 character “S” for sequela.
When appropriate, both a code for a current burn or corrosion with 7 character “A” or “D” and a burn or corrosion code with 7 character “S” may be assigned on the same record (when both a current burn and sequelae of an old burn exist). Burns and corrosions do not heal at the same rate and a current healing wound may still exist with sequela of a healed burn or corrosion. See Section I.B.10. Sequela (Late Effects)
An external cause code should be used with burns and corrosions to identify the source and intent of the burn, as well as the place where it occurred.
Codes in categories T36-T65 are combination codes that include the substance that was taken as well as the intent. No additional external cause code is required for poisonings, toxic effects, adverse effects and underdosing codes.
Do not code directly from the Table of Drugs and Chemicals. Always refer back to the Tabular List.
Use as many codes as necessary to describe completely all drugs, medicinal or biological substances.
If the same code would describe the causative agent for more than one adverse reaction, poisoning, toxic effect or underdosing, assign the code only once.
Index entries leading here 2
Alongside this code 9 same parent — T79
Additional references
Official coding advice for this code. Published by the American Hospital Association. Not included in this installation.