What are POA Indicators in Inpatient Coding?

Requirement of The POA Indicators

POA indicators is an alpha character assigned to the principal diagnosis code and any secondary diagnosis codes reported for each inpatient admission.

POA indicators are distinct from diagnosis codes and are not part of ICD 10 CM codes. Yes, they are assigned and reported to diagnosis codes, but they are different from diagnosis codes. Once the codes and POA indicator are entered, the POA indicator appears in a different data field on the claims form, separate from the ICD-10-CM diagnosis codes.

The main purpose for assigning and reporting POA indicators to ICD 10 CM diagnosis is to enable user to differentiate between diagnoses that were present on patient admission and diagnoses that developed after admission.

In Inpatient coding, new  ICD 10 PCS codes are used for reporting procedures. These codes come along with ICD 10  CM. In these set of codes, a list of root operation is given. These root of operation helps in selecting the correct ICD 10 PCS code. Below you can get more information on root of operation.

Coding tips for Root Operation EXCISION

Coding guide for Root Operation DRAINAGE

When to use Root Operation DILATION

Root Operation RESECTION Coding tips

What are POA Indicators in Inpatient Coding?

               

What is Present on Admission (POA)?

As per ICD 10 CM guidelines, the present of admission is defined as the conditions present at the time the order for inpatient admission occurs. These condition will includes also the diagnosis that develop during an outpatient encounter which lead to an admission. Even the conditions present in during in the emergency department, in observation status or in the outpatient surgery.

When there in no clear documentation for whether a condition was present on admission or not, the coder should always query the provider or physician for Clarification. There are situations where their provider needs more information which were not present at the time of discharge to determine if a conditions was POA.

If the provide clearly document that the condition was present on admission, the POA indicator Y should be assigned.

Read also: Coding tips for CPT code 36901 for AV fistula Access

POA (Present on Admission) Indicators

Guidelines of POA indicator is given in Appendix 1 of the official guidelines for coding and reporting.

POA guidelines are not used to give information on when a condition should be coded, these guidelines only guide us in assigning or applying POA indicators to the final set of diagnosis codes. 

Their are four (4) POA indicator options. 

Yes (Y)                The condition was present at the time of inpatient admission.

No (N)                The condition was not present at the time of inpatient admission.

Unknown (U)   Documentation is insufficient to determine if condition is present on admission.

Clinically Undetermined (W)    The provider was unable to clinically determine whether the condition was present on admission.

16 Thoughts to “What are POA Indicators in Inpatient Coding?”

  1. Rakesh Kumar

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  2. […]                     What are POA indicators in Inpatient Coding? […]

  3. […] Read also: What are POA indicators in inpatient Coding? […]

  4. […] is generated based on the diagnosis codes and operative procedures. But DRG codes affected with the presence of POA indicators and HAC (Hospital Acquired […]

  5. […] exam. Some of the questions are based on POA indicators, so please read first my previous post of POA indicators. Also, few question are on ICD 10 codes, do read the coding guidelines first before attempting […]

  6. Dipti Gadiya

    I am preparing for the CPC exam at end of December 2021. Please provide me any information that will guide me for an exam. I am taking the exam from AAPC. I need more information about coding guidelines also more. Thank you.

  7. […] a single code identifies both an acute and chronic condition, see the POA guidelines for codes that contain multiple clinical […]

  8. Arlene

    Hi! I would like to thank you first of all for your time and patience in giving me in site of what to expect before taking the coding exam. I’m preparing for the CPC soon and would like additional information if possible on what to study. Thanks!

  9. […] CPT/HCPCS modifiers to outpatient procedures Sequence diagnoses and procedures Apply present on admission (POA) guidelines Address coding edits Assign reimbursement classifications Abstract pertinent data from health […]

  10. […] hospital E/M codes to include “inpatient or observation” care due to the consolidation of inpatient and observation codes in […]

  11. […] Read also: What are POA indicators in Inpatient coding […]

  12. […] What POA indicator would be assigned if the patient has a history of chronic systolic congestive heart failure and […]

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