Wednesday, 29 April 2020

Present On Admission or POA

All claims submitted for in-patient admissions to general acute care hospitals or other health care facilities are required to report the POA indicator, which is assigned by the coder to the principal and secondary diagnoses and external cause of injury codes.

POA stands for Present On Admission, meaning, whether a condition was present at the time of In-patient admission or not.

CMS defines POA as PRESENT AT THE TIME THE ORDER FOR INPATIENT ADMISSION OCCURS.

POA Indicators

                 Y = Yes (Present at the time of inpatient admission)
                 N = No (Not present at the time of inpatient admission)
                 U = Unknown (Documentation is insufficient to determine if the condition was present at                             the time of inpatient admission)
                 W = Clinically undetermined (Provider is unable to clinically determine whether the                                      condition was present at the time of inpatient admission or not)

Issues related to inconsistent, missing, conflicting, or unclear documentation are resolved by the provider as a result of the physical query process. 

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