For POA, put focus on patient care not billing

Quality professionals must take the lead

When it comes to requirements for "present on admission" (POA), the focus too often is on reimbursement instead of patient care, according to some quality improvement experts.

"It is time for hospitals to quit focusing on the billing and technical aspects of the POA indicators," argues Nancy McLean, RN, BSN, MHSA, senior consultant at Courtemanche and Associates in Charlotte, NC. "POA is not a billing issue — it is a clinical quality initiative," she says. "It is time for quality professionals to take the lead and change the focus to prevention."

Since July 2007, most organizations have focused on improving licensed independent practitioner (LIP) documentation to capture as many diagnoses as possible on admission. "But when we are reporting a condition as either POA or a health care-acquired complication, it is too late to impact potential reimbursement or try to figure out how to recover uncompensated dollars spent in the treatment of health care-acquired complications," says McLean.

The loss of revenue will come from two sources, says McLean: the no pay POA complications and the resulting change in case mix index from inability to bill for secondary diagnoses that are hospital-acquired.

"We need to redirect our energy to elimination of hospital-acquired complications," she says. "It is also time for the quality professional to take the lead and change paternalism to partnership, and change the POA focus from billing to prevention."

The quality professional must lead the way in establishing the organization's POA priorities. "Quality professionals should think of a way they can add in the information that they learn from this effort to their ongoing quality improvement activities," says Beth Feldpush, senior associate director for quality at the American Hospital Association.

Answer these questions, advises McLean:

  • What has your organization done to prevent the occurrence of health care-acquired complications?
  • Have you developed plans of care that focus on prevention?
  • Are you still accepting health care-acquired complications as inevitable, an annoyance, something that can be fixed with drugs or treatments, or normal complications of a condition in certain age groups?
  • Are you paternalistic toward the patient or are you partnering with the patient? Are you complacent or are you proactive?

Request that the finance department provide you with the history of incidences of billing for the identified DRGs that will no longer be reimbursed. "Look at national data on discharge incidence of the identified POA," says McLean.

In 2000, the incidence per 100,000 discharges of decubitus ulcers was 21.96. "This was the highest of all the POA indicators selected for no payment this year," says McLean. "Review the data with leaders, and develop actions that focus on prevention."

The elimination of decubitus ulcers should be on your performance improvement plan for this year, and you should answer these questions, says McLean:

  • What is the organization's incidence of pressure ulcers? What is the incidence of the other POA complications?
  • Is the elimination or at least reduction of pressure ulcers on the performance plan this year?
  • What has the organization put in place to reduce the incidence of pressure ulcers?
  • Is the organization's focus on wound healing or on skin integrity?
  • Have we completed a literature search and sought out best practices and evidence-based literature on prevention of skin breakdown and treatment of pressure ulcers?
  • Does the organization have evidence-based wound treatment protocols approved by the medical staff?
  • Is there a certified wound care nurse on staff?
  • Is there an automatic consult to the skin integrity team when a patient is identified as at risk for skin breakdown?
  • Has the medical staff changed the history and physical requirements to include an examination for skin breakdown? Do the history requirements include a history of prior skin breakdown?
  • How does the organization respond when an LIP orders a wound treatment known to be detrimental to wound healing?
  • How has the organization's budgeting process changed to accommodate resources needed to clinically reduce or eliminate the eight health care-acquired complications identified by CMS?
  • Does the organization have a performance improvement team actively working on each of the POAs this year — or at least on the ones with the highest incidence in the organization?

Health care-acquired complications have been accepted as inevitable over the years, says McLean. "Sadly, we have to be forced into improving the quality of care we provide by CMS taking away reimbursement dollars," she says.

Reshape your performance improvement plan to focus on the list of POAs for 2008 and to begin addressing the POAs coming in 2009. "We know what complications are not being reimbursed — CMS provided us with a list," says McLean. "Stop the complication from occurring. The organization's reimbursement won't increase, but expenses will decrease. We may even improve the bottom line."

[For more information, contact:

Nancy McLean, RN, BSN, MHSA, Senior Consultant, Courtemanche and Associates, PO Box 17127, Charlotte, NC 28227. Phone: (941) 809-2092. E-mail:]