Present On Admission (POA) Status: Why Does It Matter?

Premier Pulse     June 2022

1912103631Having worked clinically as a hospitalist, I was often queried by a clinical documentation specialist (CDS) or coding specialist (CS) to document whether a particular diagnosis was “present on admission” (POA) or not. This was often a challenging question to answer as the majority of our patients do not read medical textbooks before they present to our doors. Complex clinical presentations and long length of stays made chart reviews arduous. Nevertheless, it was not until I entered into the role of physician advisor that I fully understood why POA status documentation matters.  

It did not take exceptionally long to realize that the impact was significant to both facility and provider metrics, as noted below:  

  • POA status can determine the final coded DRG (diagnosis related group), which in turn affects metrics such as CMI (case mix index), LOS (Length of stay) and hospital reimbursement.  
  • It can also significantly affect quality metrics, including CMS (Centers for Medicare and Medicaid Services) readmission metrics as well as serve as exclusions for PSIs (patient safety indicator). A good example: the diagnosis of sepsis, when present on admission, serves as an exclusion from PSI–04 sepsis mortality metric. 
  • It affects the HAC (hospital acquired condition) metric. Example: DVT or pulmonary thrombosis not present on admission equates to an HAC. 
  • In some cases, it affects the VIZIENT risk adjusted methodology (fancy word for “how sick” your patients are). 

It is important to remember acute diagnoses documented in the admission history and physical are considered POA. The qualifying principal diagnosis that necessitates hospitalization meets POA status. It is imperative to document POA status on all secondary diagnoses. As a clinician I assumed there were only two responses to the question of POA status: Yes or No. I was wrong. There is a third status as indicated below. “Clinically unable to determine” codes to a W indicator which is equivalent to POA Yes. 

In summary, document POA status on all secondary diagnoses compliantly and accurately. We owe our patients an accurate medical record that reflects the severity of illness and intensity of services provided to care for them. 

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