February 19, 2007

Budget Killer: The Pending Effects of POA
By Judy Sturgeon, CCS
For The Record
Vol. 19 No. 3 P. 6

The federal government, in compliance with the Deficit Reduction Act of 2005, has required secondary diagnosis reporting for all Medicare patients at the time of admission. I am almost certain that anyone paid by diagnosis-related groups (DRGs) on Medicare inpatients has been doing this since 1984, but evidently, there is more to be done. Beginning in October, facilities will be required to report whether or not those secondary diagnoses were present on admission (POA).

I’m still trying to tie this directive to the 2005 legislation, whose goal is to cut government spending by $40 billion over a five-year period. My initial concern is that every time Washington decides to balance the budget, it starts by trying to balance it on the backs of doctors and hospitals. Budget cuts often reduce what Medicare and Medicaid pay out, which in turn hits providers harder every year. But how is reporting POA going to help control government spending? That remains to be seen.

Rest assured, however, that it will increase spending for those involved with coding and reporting hospital claims. We’ll likely spend more time trying to find documentation validating when the onset of the condition occurred. We’ll spend more time going back to the physicians for clarification when the information isn’t available at coding. We’ll spend more money on billing delays, and we’ll see revenue loss to our facilities. So we hope it will help the federal budget because it’s going to take another bite out of hospital budgets.

Whether we like them or even understand them, we have to analyze the issues and prepare to implement the change in less than one year. The AHA Coding Clinic for ICD-9-CM for the fourth quarter of 2006 has provided direction on numerous concerns regarding the reporting of POA indicators.

On the surface, it seems simple enough. Did the diagnosis exist when the patient was admitted to the hospital? However, what if the coder doesn’t know whether the diagnosis was POA? Here, it becomes confusing. There will be a designation of “U” for unknown but not for all unknown conditions. Consider the following 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 whether the condition is POA

• W = provider is unable to clinically determine whether the condition was POA

Add to this list another option—if the condition is on the list of diagnoses exempt from reporting then the field for reporting POA indicators is to be left blank.

Let’s review several frequently asked questions.

Who reports POA indicators? Inpatient admissions to general acute care hospitals and other facilities required by law or regulation must include POA indicators on their claims beginning in October.

What gets a POA indicator? Principal and secondary diagnoses as defined in Section II of the Official Guidelines for Coding and Reporting, as well as any external cause of injury codes (E-codes).

Do POA indicators modify coding guidelines? The POA indicator is a separate issue and not a replacement or modification of existing rules for diagnosis coding. First, the coder must determine if and how a diagnosis should be reported. Once the code has been assigned correctly, only then is the POA indicator to be determined.

Why would some diagnoses not get a POA indicator? Some conditions are always POA and therefore exempt. Some code categories are exempt because they do not represent current disease or injury. Examples include but are not limited to: normal delivery, carrier of infectious disease, late effects of injuries and infections, V-codes for personal and family history of diseases, special circumstance and screening codes, E-codes for place of occurrence and motor vehicle accidents, sports injuries, and acts of war.

Why do only some E-codes get a POA indicator? Some external events, by their definition, could happen in either patient status. The patient can slip and fall at home or after admission. Poisonings and adverse effects of drugs could happen at home, in the emergency department (ED), or after admission to the hospital.

Do newborns automatically get a POA indicator of Y? Usually but not automatically. Congenital conditions and diagnoses that developed in utero or during delivery get a Y indicator. On the other hand, the baby may still be in the perinatal period but develop a diagnosis such as infection or injury after admission. These types of diagnoses would receive a POA indicator of N.

Are chronic conditions such as diabetes and chronic obstructive pulmonary disease always considered POA? Combination codes are tricky. If all components of the code are POA, it receives a Y. If any of the code’s components developed after admission, however, the POA will be N. Example: a diabetic patient who is controlled at admission but becomes uncontrolled later in the stay would be status N because the loss-of-control portion of the combined code occurred after admission. A patient admitted with asthma whose status remains constant during the admission would get an indicator of Y. However, if on day three after admission the patient developed an acute exacerbation of the chronic asthma, the indicator would be N.

An exacerbation of congestive heart failure (CHF) is not necessarily the same POA indicator as an asthma exacerbation. Why? The code for CHF does not include a component to describe acute exacerbation. If a patient is admitted with CHF and later experiences an acute exacerbation, the indicator would still be Y.

How does the possible/probable rule affect POA indicator? If the final diagnosis is still described as possible/probable and the diagnosis was suspected at the time of admission, then the indicator is Y. When the determination of a possible/probable final diagnosis is based on information such as symptoms or lab findings and they were not POA, then the indicator would be N. This concept applies to impending or threatened final diagnoses as well.

When do we query the physician? If the documentation already indicates that the provider cannot determine the condition’s onset, indicator W should be used. If the documentation does not indicate the presence or absence of the diagnosis when the patient was admitted, the coder is directed to use indicator U. Directions in the applicable Coding Clinic state that “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.”

As you can see, this new coding and reporting requirement will bring even more documentation challenges to your facility—along with new headaches for your coding and billing staff. Good documentation from the ED and on the history and physical will be even more critical than it already is. Start priming your doctors and “qualified healthcare practitioners who are legally accountable for establishing the patient’s diagnosis.” It is apparent that we will need even more specific information from them in the near future.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 18 years.

For more detailed information on POA indicators, try the AHA Coding Clinic for ICD-9-CM, 4th Quarter, 2006, where you will find extensive explanation, examples, and details in Appendix 1 of the Official Coding Guidelines, pages 241 to 255. The Web site containing the Official Coding Guidelines also has the appendix for POA reporting, which can be found on pages 91 to 102 at cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf.