Present on Admission Indicators Presented By: Cindy Basham, MHA, BSN, CCS, CPC Shannon McCall, RHIA, CCS, CPC Have you ever noticed that everything in healthcare is an acronym or abbreviation? It’s like a foreign language. Have you ever been talking to a non health care worker and they get that confused look on their face when you start discussing your job? “Well, the physician documented on the H&P that the patient had CHF, elevated BP, Afib and possible PE. Some of the other diagnoses were illegible- I think it may have said that they had a possible AMI so they performed a TEE and EKG. We need to query so that on our UB’s it groups to the correct DRG because an AMI is a MCC. So let’s look at another acronym, POA!

Short Background on POA’s Required by the Deficit Reduction Act of 2005 Only for acute inpatient hospital admissions

Who’s Exempt from Reporting? Critical Access Hospitals (CAH) Maryland Waiver Hospitals LTCHs Cancer Hospitals Children’s Inpatient Facilities

POA Reporting Periods Reporting time periods “Introductory” reporting for discharges on or after 10/1/2007 Claims will not be rejected or denied due to lack of POA assignment “Interim” reporting for discharges after 1/1/2008 Claims will process without POA but a remark code on the EOB will print for correct POA assignments. “Mandatory” reporting effective 4/1/2008 Claims will be returned for POA information. We are all now in the “mandatory” time period so if you haven’t been reporting POAs, if we listen closely we can hear all of your CFO’s screaming! 

Which codes need POA’s? Principal diagnosis Other (i.e. secondary) diagnoses Remember! Codes MUST still meet the requirements by the Official Guidelines for Coding and Reporting. clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring.

Exemptions? Diagnoses exempt from POA Reporting are generally: Late effect codes History codes Status post codes Body mass index (BMI codes) Most E codes (but not all) For a complete list see attachment

How do they appear on a claim? Paper Claims (UB-04) 8th digit of field locator (FL) 67 Shaded box (see attachment) Electronic Claims (8371) Listed in sequence starting after “POA” For example POAYYN1Z means the POAs are: “Yes” principal diagnosis; “Yes” for other diagnosis #1, “No” for #2, “Exempt” for #3 and Z indicates the end of the string.

POA Indicators Y= Yes the condition was present on admission N= No the condition was not present on admission 1= Unreported/not used or Exempt from POA reporting This is the equivalent of a “blank” These are when you KNOW one way or the other.

POA Indicators U= Unknown because the documentation is insufficient W= Clinically undetermined by the provider “Do you have trouble making up your mind? Well, yes or no?”- Anonymous

Reporting “Y” Explicitly documented as being present on admission Conditions diagnosed prior to admission Conditions diagnosed during the admission but were clearly present Condition developed prior to written order for inpatient admission.

What is considered prior to admission? Conditions present at the time the inpatient order is written Includes conditions that develop during encounters in: Outpatient Emergency department Observation Outpatient surgery

Reporting “N” Condition explicitly documented as NOT being present on admission Final diagnosis documented as probable, possible etc. based on symptoms not present on admission How likely is this? How many doctors will say he definitely does NOT have this condition…

Reporting “1” Diagnosis is on the list of exempted codes

Reporting “U” Medical record is unclear Should be used infrequently Physician should be queried for clarification Under the Proposed Rule for FY 2009, U’s will be treated the same as a N. This will provide additional incentive to want to get clarification from the physician.

Reporting “W” Medical record indicates it cannot be clinically determined if condition was present This can be used in situations where a patient may have many conditions superimposed on each other to where it is clinically impossible to state with all certainty whether a condition was present on admission.

Appropriate sources for documentation Per CMS, any “provider” involved in the care and treatment of a patient. Per the Official Coding Guidelines for POAs, the term provider means a physician or any qualified health care practitioner.

What is considered a physician? Further clarification, per CMS the term “physician” is limited to doctors of: medicine osteopathy dental surgery or of dental medicine podiatry optometry

What is considered a practitioner? Further clarification, per CMS the term “practitioner” is limited to: Physician assistant Nurse practitioner Clinical nurse specialist Certified registered nurse anesthetist Certified nurse midwife Clinical psychologist Clinical social worker Registered dietitian or nutrition professional

Limitations Don’t forget the rules for code assignment!! “If a condition would not be coded and reported based on the UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported” <POA Guidelines>.

Limitations Per the AHA Coding Clinic 1Q 2004, code assignment is generally only based on physician’s documentation in the care of a patient. Documented diagnoses by individuals other than physician’s generally should be clarified by a physician query. Exception– BMI’s can be coded from a dietician’s note per AHA, Coding Clinic, 4Q 2005 These are exempt anyway from POA indicators!

Best sources in the medical record for documentation Emergency department notes (if applicable) H & P (by attending or other physician) Physician’s progress notes Physician’s admit orders

Specific POA Reporting Acute and Chronic Conditions Acute “Y” if present on admission; “N” not present on admission Chronic “Y” even if diagnosed after admission But what about obesity and substance abuse/dependence. Not a true chronic condition but would have had to have existed prior to admission. The question is if the code says “chronic” in the title should it always be assigned a POA of “Y” as well? Some chronic conditions do explicitly state they are chronic like COPD or Chronic bronchitis but others do not explicitly state in the code title it is a chronic condition like Parkinson’s or hypertension or diabetes. There really isn’t a list of true chronic conditions. In fact some conditions seem like they would always be present on admission but aren’t on the exempt list like obesity, tobacco use etc.

Specific POA Reporting Combination Codes “Y” if all parts were present on admission Inguinal hernia with obstruction “N” if all parts were not present on admission Obstruction occurred after admission These can also present a challenge when you have a condition that is considered a chronic condition but is assigned a combination code. For example, diabetic ketoacidosis. If the patient was admitted for an unrelated problem like an acute MI and had a documented secondary diagnosis of diabetes mellitus. DM is a chronic condition assigned to code 250.xx. But, if during the admission the patient developed diabetic ketoacidosis assigned to combination code 250.1x. Since it is a combination code, the POA would be a “N” because the ketoacidosis did not occur until after the admisison.

Specific POA Reporting Combination Infection Codes (include disease and infectious organism) “Y” even if the infection culture was not known until after admission Klebsiella pneumonia This guideline does not further identify when you have non-combination codes like UTI due to E-coli. It would be presumed that even if the culture was not known until after admission that the E-coli code (041.4) would also get a POA of a “Y” to follow suit with this general guideline.

Specific POA Reporting Obstetrical conditions Delivering during an admission does not affect POA assignment. Was pregnancy complication or condition present on admission? Yes= “Y” Breech presentation and delivers during admission No= “N” Vaginal laceration during delivery

Specific POA Reporting Perinatal/congenital conditions Newborns are “admitted” after birth Any condition present during delivery, in utero or during the delivery are assigned a “Y”. Includes congenital anomalies Conditions developing after birth are assigned a “N”. For example, a baby who is born with dependence on cocaine would be assigned a “Y” considering it developed in utero. Similarly, a baby born with polydactyly would be assigned a POA of “Y”. However, a baby born and develops respiratory distress 3 hours after delivery would be assigned a “N”.

Specific POA Reporting E codes For all E codes (that are not exempt) Assign “Y” for any external causes suffered prior to admission Assign “N” for any external causes suffered during the hospitalization

Hospital Acquired Conditions The Deficit Reduction Act (DRA) of 2005 requires quality adjustment for MS-DRG payment for certain hospital acquired conditions. HAC’s caused by medical errors are the leading cause of morbidity and mortality in the US. Treating these conditions are also a burden weighing in at an average of 5 billion dollars each year. HAC provisions are to promote efficient and quality health care.

Hospital Acquired Conditions CMS had to choose at least two conditions that are considered: High cost and/or high volume Result in a higher paying DRG when assigned as an other (“secondary”) diagnosis Could have been prevented through evidence-based guidelines Presently, hospitals receive the same payment regardless of lengths of stay if assigned to the same DRG. In many cases, the hospital would get the same payment for an admission regardless of whether a complication was suffered during the hospitalization. But, in some cases they can impact payment---1) increase in resources could result in an outlier payment (but it would have to be a significant loss). OR 2) if the assignment of the HAC as a secondary diagnosis causes the admission to group to a higher paying DRG (e.g., with CC or with MCC).

Hospital Acquired Conditions Conditions with payment implications effective 10/1/2008 Serious Preventable Events Object left in during surgery (998.4 CC) Air embolism (999.1 MCC) Blood incompatibility (999.6 CC) Catheter Associated UTIs 996.64 CC and a urinary infection categories 112, 590, 595, 597, 599) Would have to be the sole CC or MCC on admission. If another condition was a MCC or CC condition it will still group to the higher paying DRG or will also group to the higher paying DRG if the condition was present on admission.

Hospital Acquired Conditions Proposed conditions with payment implications effective 10/1/2008 Pressure Ulcers (707.00, 707.01, 707.09 CCs or 707.02-707.07 MCCs) Vascular Catheter Associated Infection (999.31 CC) Surgical Site Infection – Mediastinitis after CABG (519.2 MCC plus 36.10-36.19) Fall and Trauma (Codes TBA in 2009 Proposed Rule Per the Proposed Rule, HACs assigned a Y or a W will be paid as a DRG with CC or MCC. W’s should be considered a rarity that the physician cannot truly clinically determine when the onset occurred. W’s will be scrutinized over the next year for its use as well as whether the Y is used appropriately. HACs assigned a N or U will not be paid at the higher reimbursing DRG. By not paying the U indicator is supposed to foster better documentation by providers. Please note that currently for pressure ulcers depending on location can be considered either a CC or an MCC. For FY 2009, the new codes proposed for decubitus ulcers will be assigned by the stage of the ulcer. Stage III and IV would be considered MCCs whereas Stages I-II or unspecified would be neither a CC or MCC.. The most costly of the HAC’s resource-wise is Medistinitis after CABG which on average increases in costs of approx. $300K/hospital stay. The mediastinitis is assigned with a combination of codes. The coder would have to identify both the diagnosis and the procedure code. The proposed rule announced the code series for falls/trauma would include Fractures and Dislocations (800-839), intracranial injuries (850-854), crushing injuries (925-929), Burns (940-949) and other effects of temperature, light, air pressure etc (991-994). The most common occurrences were for the Pressure (decubitus ulcers) and Falls/Trauma.

Hospital Acquired Conditions Conditions still being considered for FY 2009 Ventilator associated pneumonia Staph A septicemia DVT PE Proposed rule also added: Surgical site infections following elective surgeries (mediastinitis was pinpointed as definite because this was a broad category), Legionnares Disease (type of pneumonia due to inhaled contaminated water droplets or vapors) Thrives in an large industrial water system like hospital air cooling towers); Glycemic control (e.g., ketoacidosis, diabetic hypoglycemia, diabetic coma) Severe conditions relating to glycemic control should not occur while under a medical care setting.; Iatrogenic pneumothorax (where air is accidentally introduced into the pleural space causing the lung to collapse partially or completely) can occur with any procedure involving the pleural space, thoracentesis, pleural biopsy or needle biopsy of the lung. Delirium (abrupt deterioration of ability to sustain attention, learning or reasoning). VAP has a proposed new code for 2009 (997.31). It would be another combination coding scenario where it would be identified with the complication code (997.31) plus an additional diagnosis code from the respiratory system to identify the type of pneumonia and a procedure code for the mechanical ventilation. Caused by the aspiration of contaminated gastric and/or oropharyngeal secretions. The endotracheal tube facilitates this contamination as well as the aspiration. Staph A Septicemia- Bacterium which lives in the nose and on the skin of most people and does not cause illness. But, it can cause illness if it enters through the bloodstream due to trauma or during an invasive surgery. DVT/PE- This is a condition that can be difficult to detect on admission considering the clot could be present but the symptoms do not appear until after admission which would render it is an automatic POA of “N”.

Hospital Acquired Conditions Conditions requiring further analysis MRSA Clostridium difficile-associated disease Wrong surgery MRSA- New codes were proposed for this condition at the March 19-20 ICD-9 Coordination Committee. The codes would identify specific infections due to MRSA. Currently only classified as V09.0 (non-CC) condition. MRSA is currently covered by the HAC provisions in the fact that for each infection that has already been selected MRSA could be the cause of that infection (eg. Vascular catheter associated infection due to MRSA). This condition is not presently known as being reasonably preventable nor is it considered a CC condition which eliminates two out of the three criteria for being considered as a HAC. The mere presence of MRSA is not considered a HAC. Clostridum difficile associated disease- colonizes in the GI system in a certain number of healthy people. Sometimes when the normal flora is disrupted it can cause the c-dfficile to flourish and cause severe diarrhea and potentially colitis. The spores can live outside the body for months.

Hospital Acquired Conditions Roadblocks to implementing Codes have to be specific for the HAC Codes have to be identified as a MCC or CC condition Combination codes Some conditions are not all hospital acquired Currently, Ventilator associated pneumonia still assigned 999.9 (not specific). For FY 2009, new code 997.31 is being proposed. MRSA assigned V09.0 (not just for MRSA can be used for all “cillin drugs). Proposed new code for more specificity for FY 2009. Combination codes can present problems if coded incorrectly. For example- Mediastinitis after CABG it would be a combination of dx and procedure codes.

Why do we need POAs and HACs? Assists in CMS’s step towards Value-Based Purchasing CMS wants to be an “active payer” rather than a “passive payer”. CMS wants to actively promote quality care not just reimburse based on quantity of care.

Case Study #1 An elderly female is admitted for newly found acute left systolic heart failure and acute urinary tract infection. A urine culture confirmed the UTI was due to E. Coli. The patient’s medical history includes diabetes mellitus, and a long history of UTIs. All diagnoses were determined to be pertinent to the admission by the attending physician. The discharge summary identifies the newly found acute left systolic heart failure to be the principal diagnosis. The UTI was treated with Bactrim and the diabetes was evaluated and treated with Glucophage at the same dose as her home medication.

Case Study #1 POAs ? Acute left systolic heart failure (428.21)_______ Acute UTI (599.0)_________ E. Coli infection (041.4)_________ Diabetes mellitus (250.00)__________ History of UTIs (V13.02)___________

Case Study #1 POAs Answer Y – present at the time of admission Y – present at time of admission Y – Infection codes are considered present at the time of admission even if the culture is not confirmed until after admission 1 – this code does not represent a current disease and are always present on admission; therefore are exempt from POA reporting

Case Study #2 A patient with a history of Type 1 diabetes mellitus is admitted to the hospital for acute pneumonia. On day 3 of the hospitalization, the patient’s diabetes became uncontrolled requiring the adjustment of the insulin regimen. The discharge summary identifies the acute pneumonia as the principal diagnosis and uncontrolled diabetes as a secondary diagnosis.

Case Study #2 POAs ? Pneumonia, acute (486)_________ Diabetes uncontrolled, Type 1 (250.03)_________

Case Study #2 POAs Answers Y – present at time of admission. N – assign “N” since the uncontrolled component of the code was not present at the time of admission

Case Study #3 The nursing initial assessment upon admission documents the presence of a sacral decubitus ulcer. There is no mention of the decubitus ulcer in the physician documentation until several days after admission and the documentation does not clarify the presence on admission.

Case Study #3 POAs ? Decubitus ulcer, sacral (707.03) ____________ The importance of the correct code assignment is that if this was the only MCC condition on the record effective 10/1 2008 this would not result in a higher paying DRG without clarification of whether this condition is present on admission.

Case Study #3 POA Answer U – documentation is insufficient to determine if the condition is present on admission. Query the physician as to whether the decubitus ulcer was present on admission, or developed after admission. Both the diagnosis code assignment and determination of whether a condition was present on admission must be based on the provider’s documentation in the medical record U’s are proposed to be treated as if it was a N indicator which would result in the lower paying DRG without CC or MCC.

Case Study #4 A patient with a PICC line is admitted for treatment of cachexia due to severe malnutrition after not responding to outpatient treatment with peripheral parenteral nutrition (PPN). The PICC line was changed after admission. On the 2nd day, the patient had an elevated temperature (102.5o) and a WBC of 14,000 and 85% neutrophils. Blood cultures were positive for Staphylococcus Aureus. The discharge summary identifies the PDx as cachexia with severe malnutrition and a secondary diagnosis of a staphylococcus infection due to the PICC line. 45

Case Study #4 POAs ? Severe malnutrition (261) ______ Cachexia (799.4)______ Catheter-related infection due to Staphylococcus A (999.31)___ (041.11) ___ See note at Cachexia (799.4) to code first underlying disease 46

Case Study #4 POAs Answers Y- condition diagnosed prior to admission Y- conditions diagnosed prior to admission are considered present on admission U- documentation is insufficient to determine if the condition is present on admission. Query the physician as to whether the infection was present on admission, or developed after the PICC line was changed. In this case, the infection could have resulted from the initial PICC line when the patient was admitted OR it could have resulted from the change in PICC line the 2nd day of the admission. In this case, it may truly be clinically impossible for the physician to determine which occurred since no studies were performed to detect the absence of an infectious process on admission. 47

Case Study #5 A patient with atrial fibrillation and on long time therapy with Coumadin undergoes outpatient surgery. During the recovery period, the patient develops a postoperative hematoma because of his chronic anticoagulation and his H&H drops to 7.0 and 28 respectively. The patient is subsequently admitted to the hospital as an inpatient for stabilization with transfusions. The physician documents acute postoperative hematoma complication of outpatient surgery due to Coumadin use as the principal diagnosis. The physician also documented anemia on postoperative day #2. The patient received a total of four units of PRBCs during the inpatient stay.

Case Study #5 POAs ? Postoperative hematoma following surgery (998.12) _____; (E878.9) _____; (E849.7)______ Anemia (285.9) _____ Chronic anticoagulation (V58.61) _____; (E934.2) ______ Atrial fibrillation (427.31) ______ Per Coding Clinic, 1Q, 2007 Anemia cannot be coded as acute blood loss anemia even if documented in the postop period without specific documentation. Code 285.1, Acute blood loss anemia, should be assigned, when postoperative anemia is due to acute blood loss. Revisions were made to the Alphabetic index in 2004, which directs the coder to the appropriate code assignment. The physician did not document the anemia as being due to blood loss.

Case Study #5 POAs Answers Y- for 998.12 because this condition occurred in outpatient setting prior to the written order for admission as inpatient; Y- for E878.9 because it happened prior to inpatient order written. Y- for E849.7 because it happened prior to inpatient order written. Y- lab findings (signs) were documented for this condition prior to inpatient order written 1- this code does not represent a current disease and is always present on admission therefore it is exempt; Y- condition occurred in outpatient setting prior to inpatient order written Y- condition diagnosed prior to admission are considered present on admission For anemia, the low H & H was the symptom present on admission.

Case Study #6 A 39 year old patient with no known health history is found unresponsive on the sidewalk in front of her office. She is placed on a mechanical ventilator in the emergency room and admitted to the ICU. After study it is determined she suffered an acute pulmonary embolism which is the primary cause of her admission. Admission labs include Glucose > 400; Bun 28 and Creatinine 1.9. The discharge summary lists the principal diagnosis as Acute Pulmonary Embolism with additional diagnoses of new onset Type 2 DM, and new onset acute renal insufficiency.

Case Study #6 POAs ? Acute pulmonary embolism (415.19) ______ Type 2 DM (250.00) _____ Acute renal insufficiency (593.9) _______

Case Study #6 POAs Answers Y- condition developed prior to admission Y- even though it was discovered after admission the evidence clearly supports the condition was present prior to admission.

Sources CMS Present on Admission Indicator Reporting by Acute IPPS- December 2007 CMS Transmittal 289, CR 5679, July 20, 2007 ICD-9-Official Guidelines for Coding and Reporting, Effective 10/1/2007 MLN Matters Number: MM5499, May 11, 2007 CMS Hospital Acquired Conditions in Acute IPPS-December 2007 CMS Benefit Policy Manual, Pub 100-02, Chapter 15, §40.4 AHA Coding Clinics 54