AHA Coding Clinic® for ICD-9 - 2008 Issue 3
Notice
Section 5001(c) of Pub. L. 109-71 requires the Secretary of the Department of Health and Human Services to identify a list of hospital-acquired conditions and to collect information regarding such conditions. The Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) has developed a process for hospitals to submit a Present on Admission (POA) indicator with each diagnosis. For more specific instructions on Medicare POA indicator reporting instructions, refer to http://www.cms.hhs.gov/HospitalAcqCond/02_Statute_Regulations_Program_Instructions.asp#TopOfPage The American Hospital Association (AHA) and the Centers for Medicare & Medicaid Services (CMS) are collaborating on the...
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Article Overview
This article is a policy and coding guidance notice focused on hospital-acquired conditions and present-on-admission (POA) reporting under Medicare. It summarizes the role of CMS, AHA, and the ICD-9-CM Cooperating Parties, and it addresses common questions about POA indicator reporting, documentation timing, and related reporting considerations. It is intended for hospital coders, CDI staff, and compliance teams that work with inpatient diagnosis reporting and POA documentation.
Why This Topic Matters
Accurate POA reporting affects inpatient diagnosis data collection and Medicare-related hospital reporting processes. Readers who handle coding, documentation review, or compliance can use this article to understand the scope of the guidance and the kinds of POA questions the source addresses.
Article Sections
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Hospital-acquired conditions and POA reporting background
Introduces the federal basis for hospital-acquired condition tracking and the CMS process for submitting POA indicators with diagnoses. It also notes the collaboration between CMS and the AHA.
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Frequently Asked POA Questions
Presents recurring questions and answers about POA reporting, documentation timing, and related coding concerns in the hospital setting.
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Question on documentation timing and physician queries
Addresses whether timing expectations exist for documenting that a condition was present on admission and discusses clarification of unclear documentation.
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Question on POA indicators for E-codes
Begins a discussion of whether certain diagnosis-related external cause codes require POA indicator assignment.
What You Will Learn
- The federal and organizational context for POA reporting guidance
- How the article frames common POA documentation and reporting questions
- Which types of coding and compliance issues are discussed in relation to inpatient diagnosis reporting
- The general scope of CMS and AHA involvement in POA guidance
- The kinds of reporting concerns raised about diagnosis-related code categories
Who Should Read This
- Hospital coders
- Clinical documentation integrity staff
- Coding managers
- Compliance professionals
- Revenue cycle teams
- Inpatient quality reporting staff
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