Present on Admission Reporting Guidelines Course

Description

In this course, coders will gain comprehensive insights into the crucial task of assigning Present on Admission (POA) indicators for diagnoses and external causes of injury codes on claim forms. This course supplements the ICD-10-CM Official Guidelines for Coding and Reporting, focusing on how to accurately apply POA indicators to diagnoses in accordance with established coding guidelines. Participants will learn about the various reporting options and definitions, ensuring that diagnoses are correctly classified as 'present at the time of inpatient admission' or otherwise. Additionally, the course covers scenarios involving chronic conditions, acute exacerbations, obstetrical and perinatal conditions, congenital anomalies, and external cause of injury codes.

Included Lessons:

Official Guidelines for Coding and Reporting

Key Takeaways

POA Indicator Proficiency: Coders will have a deep understanding of how to assign Present on Admission (POA) indicators accurately for diagnoses and external cause of injury codes. They will be able to determine whether a condition was present at the time of inpatient admission, ensuring compliance with coding guidelines.
Comprehensive Documentation: Participants will learn to evaluate medical record documentation thoroughly to identify conditions that should receive a POA indicator. They will gain skills in recognizing consistent and complete documentation, which is essential for accurate coding and reporting.
Reporting Options Mastery: Coders will be proficient in using the reporting options 'Y' (present at admission), 'N' (not present at admission), 'U' (documentation insufficient), and 'W' (clinically undetermined). They will know when and how to apply each option based on the provided guidelines.
Chronic and Acute Condition Coding: Participants will understand how to assign POA indicators for chronic conditions, even when diagnosed after admission, and for acute conditions present at the time of admission. They will also grasp the nuances of coding conditions with acute exacerbations.
Special Cases Handling: Coders will be equipped to handle special cases such as obstetrical conditions, perinatal conditions, congenital anomalies, and external causes of injury codes. They will know how to assign indicators based on the specific circumstances surrounding each case.
Effective Querying: Participants will learn the importance of querying healthcare providers when documentation is unclear. They will be skilled in crafting effective queries to obtain the necessary information for POA determination.
Exempt Codes Knowledge: Coders will be aware of categories and codes exempt from POA reporting and understand when it is appropriate to leave the 'present on admission' field blank.

What is the purpose of assigning Present on Admission (POA) indicators?

The primary purpose of assigning POA indicators is to determine whether a diagnosis or condition was present at the time of inpatient admission. It helps in identifying conditions that were not caused by the hospitalization itself, impacting reimbursement and quality reporting.

Are there any exemptions to assigning POA indicators?

Yes, there are certain categories and codes exempt from the requirement to assign POA indicators. These exemptions are typically for codes representing conditions that are always present on admission or circumstances that do not involve a current disease or injury. You can refer to the exempt list provided in the guidelines.

About our Medical Coding Courses

HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a comprehensive online education platform for medical coders. With a catalog of over 200 medical coding courses accepted by the American Health Information Management Association (AHIMA) for Continuing Education Units (CEUs) and a selection approved by the American Academy of Professional Coders (AAPC), HIAlearn caters to both beginners and experienced medical coders seeking to enhance their skills. The platform provides an array of training plans tailored to meet individual learning needs, from mastering challenging coding procedures to understanding broad conceptual frameworks within the coding world. Courses are available across various coding types including CPT, E/M, ICD-10-CM, ICD-10-PCS, and are designed to cater to different coder levels and coding specialties such as inpatient, outpatient, profee, and CDI. Additionally, HIAlearn offers a Coding Updates bundle to ensure coders are up-to-date with the annual changes in ICD-10-CM, ICD-10-PCS, CPT, and IPPS. Beyond individual learning, HIAlearn supports organizations with group discounts, promoting enhanced coding accuracy, efficiency, and compliance across teams.