Q&A: Documenting present on admission status for wounds

Q: If I document a wound at Stage 3 with no CC or MCC, do I also need to assign a present on admission (POA) status?

A: Every diagnosis reported (unless exempt) require a POA status. The only categories of exemptions are usually cause of injury and/or status codes. “Wound” by itself is insufficient to be further categorized as a CC or MCC. Wound defaults in ICD-10 to traumatic wounds. Only pressure injuries, stage 3 and 4, and certain locations of non-pressure ulcers qualify as comorbidities. Furthermore, if a pressure injury is not POA and receives a POA indicator of N, it will not be paid as a comorbidity and will not be reflected in the final DRG as such for most payers (DRG Payers, specifically Medicare per the hospital-acquired condition program).

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.