Book excerpt: POA criteria

By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, and Sharme Brodie, RN, CCDS

The inpatient prospective payment system (IPPS) requires all facilities to report a present on admission (POA) indicator (or code) for all claims. There is no required time frame as to when a provider must identify or document a condition as POA. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis and such determinations may take a period of time after admission to clarify.

Consider, for example, an elderly female admitted for pneumonia and acute respiratory failure, who is immobile at the time of her arrival. Clinicians attribute this to her compromised respiratory status. Then on day two, clinical staff discover a fracture of the femoral neck and when asked, the patient states she has been experiencing pain in her left leg and a very unsteady gait over the past 10 days. Often, injuries like this may not be recognized at the time of the admission as the clinical team focuses on the patient’s more urgent issues, in this case the respiratory failure and pneumonia.

A few days later when the nurse encourages ambulation and notices the injury, brings it to the physician’s attention, and appropriate treatment begins. In this case, if documentation isn’t clear, the CDI professional might query the provider to clarify if the femoral fracture was POA. Providers need to understand that their clinical judgment should support the clarification of this issue based on the patient’s history and presentation.

It should be noted, conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery prior to a formal inpatient admission, are considered POA. For example, a patient is placed in observation for the diagnosis of syncope and falls and breaks her femur. The physician then admits her to inpatient status so that she can undergo a total hip arthroplasty. Because the fractured hip was present at the time the inpatient order was written, it would not be considered a hospital acquired condition. This is often a difficult concept for providers to understand, as they usually see any overnight stay as being an admission.

Editor’s note: This article is an excerpt from The Essential Guide to Supporting Quality Care Measures Through Documentation Improvement.