HCPro, JustCoding Inpatient - 2018 Issue 20 (May)
Q&A: Querying for POA pressure ulcer diagnoses
May 15th, 2018
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Article Overview
This article addresses a common inpatient coding and compliance question about assessing pressure ulcer status at admission when the diagnosis appears later in the stay. It focuses on the role of admission and initial nursing documentation, the need to consider hospital-acquired condition implications, and when a query to the physician may be appropriate. The piece is useful for coding professionals, CDI staff, and compliance teams working with ICD-10-CM pressure ulcer documentation and POA determination.
Why This Topic Matters
Determining pressure ulcer present-on-admission status can affect quality reporting, hospital-acquired condition review, and reimbursement-related case mix impacts. The article helps readers understand the documentation sources to review before deciding whether clarification is needed.
What You Will Learn
- How documentation timing affects pressure ulcer present-on-admission review
- Which admission records may be helpful when evaluating a pressure ulcer
- When physician clarification may be considered
- Why POA status can matter for hospital-acquired condition and reimbursement review
Who Should Read This
- Inpatient coders
- Clinical documentation integrity specialists
- Coding managers
- Compliance staff
- Health information management professionals
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