Confront data challenges for 'present on admission' before it's too late

Conditions may be wrongly identified as hospital-acquired

Making sure that conditions that are "present on admission" (POA) are identified as such. Using newly acquired data to identify potential quality issues. Dealing with physicians who refuse to conform to new documentation requirements. These are three big challenges quality professionals are facing, in light of new requirements for reporting of POA data by the Centers for Medicare & Medicaid Services (CMS).

CMS will not pay for these eight preventable conditions unless they are documented as POA: objects left in patients during surgery, air embolism, blood incompatibility, catheter-associated urinary tract infections, pressure ulcers, vascular catheter-associated infections, mediastinitis after coronary artery bypass graft surgery, and patient falls.

Data submitted in fiscal year 2008 will be analyzed by CMS, and may potentially be incorporated into future POA regulations. (For more information, visit

"Be a proactive advocate for data quality in your organization to assure high levels of data integrity in POA reporting," says Carol Spencer, RHIA, manager of professional practice resources at the American Health Information Management Association.

Your organization should already have done an internal assessment to determine its capacity to meet the new requirements, says Beth Feldpush, senior associate director for quality at the American Hospital Association. "This really requires a coordinated approach among the hospital staff, with nurses, physicians, medical coders, and billing staff — even the software vendors that hospitals contract with for their billing systems," she says. "They will all have to work together to implement this successfully."

Here are steps to take now:

• Analyze, trend, and report findings.

"We are doing a monthly analysis of cases which are identified as not being POA, to learn if any patterns or trends exist," says Cindy Dougherty, RN, CPHQ, director of quality measurement and improvement at Northwest Community Hospital in Arlington Heights, IL.

Cases that trigger the "N" (not present at the time of inpatient admission) indicator are reviewed to determine if improvements are needed in documentation or adherence to established policy and procedure, says Dougherty.

If case-specific data aren't being entered into a database, then data collection and tracking systems will be necessary along with report writing capability, says Spencer. This could be part of the health information abstracting system, or a separate Excel or Access database.

"We have been tracking our internal data on adverse events and complications, and will continue to do. But we will now distinguish between those that are reported as 'POA' and those that were not present on admission," says Sharon Kostroski, vice president of quality and safety at St. Joseph's Hospital in Marshfield, WI.

Collect case-specific information on all "N," "U" (documentation is insufficient to determine if the condition is present at the time of inpatient admission), and "W" (the provider is unable to clinically determine if the condition is present on admission) assignments.

This is imperative for root cause analysis and trending, so improvements can be made in the quality of care, documentation, and accuracy in POA assignment. "CMS anticipates a steady downward trend of 'U' assignments," says Spencer. "Without facilities reviewing and trending for themselves, this could leave a facility exposed for a potential audit."

• Educate physicians about new documentation requirements.

"We have had to provide education and follow-up with our medical staff regarding the need to document in a way that clearly defines whether or not a condition was present on admission and the consequences of not documenting accurately," says Kostroski.

Use a variety of instructional methods and techniques, and give one-on-one education to physicians when possible, recommends Spencer.

A common problem is that several days after admission, physicians may start documenting conditions that were not mentioned in the history and physical (H&P) report or initial progress notes. "It is difficult to determine if the condition is hospital-acquired, or if the physician simply noticed it later and now is addressing it," says Spencer.

Conditions such as anemia, electrolyte deficiencies, and various cardiac arrhythmias are likely not hospital-acquired, and were actually chronic conditions that just weren't addressed before the lab values came back. "These cases would be queried, and thus answered 'U' until the physician answers the query," Spencer says.

Create physician query forms for the eight hospital-acquired conditions required for reporting in fiscal year 2008, advises Spencer. The format will vary from organization to organization, depending on the degree of electronic system implementation.

"Some are initiated to the physician concurrently while the patient is in the hospital and some are initiated retrospectively but before the bill drops," says Spencer. "Some query forms are open-ended questions and some are check-off boxes. The key is to not 'lead' the physician to a particular response."

• Be prepared to add additional conditions.

Coding staff are reporting data on every diagnosis, but clinical teams may be focusing solely on the required eight conditions. "The challenge is to keep a pulse on not only those eight conditions, but also be prepared to react to additional conditions that may be added next year," says Spencer.

• Consider reducing productivity requirements of coders.

This may be necessary, as coders now spend more time reviewing nursing admission assessments and diagnostics such as lab reports. Catheter-associated urinary tract infections and pressure ulcers are the most commonly queried conditions of the eight.

"If documentation supports a potential query, then this also takes additional time," says Spencer. "The challenge is to provide quality-coded data, meet productivity requirements, and adhere to billhold demands."

• Determine what data will be collected and entered into the POA database.

"This is another important exercise not to be overlooked," says Spencer. "If your facility has not performed this important function, then this is a good agenda topic for your next interdisciplinary POA meeting."

You'll need to determine what kinds of reports will be run, how often, and who will receive them. "Being able to understand the data and report the results is a key step in performing root cause analysis and implementing process improvements," says Spencer.

During a root cause analysis, analyze data on the nursing unit, the attending physician, whether a case was queried, the coder, the POA assignment, whether the case was rebilled, the potential financial impact, the potential quality impact, the payer, and the root cause.

Data also can be analyzed by ICD-9-CM code and reported by high frequency codes of "N," "U," or "W" to identify potential areas for education and training. Determine if the issue is related to coding, physician documentation, systems design and interfaces, or policies and procedures, says Spencer.

• Ensure documentation is captured at the time of admission.

Forms may need to be revised, such as adding a prompt for a skin examination to the H&P. "This will assist in data capture at admission," says Spencer. "Adding a physician signature line to wound care assessments is another avenue for securing physician documentation for POA assignment."

• Establish an interdisciplinary workgroup.

"The scope of individuals within the organization that impact or have the potential to impact POA is great," says Dougherty.

Involve health information management, coding, nursing, infection control, wound care, surgery, medical staff, and administration. "Also include patient satisfaction, in order to track and trend problem areas, in an effort to address quality issues and prepare for the potential reimbursement impact next year," says Spencer.

• Avoid erroneous identification.

Without appropriate documentation and assessment, organizations may be identifying conditions as hospital-acquired when they are not. "This is a potential problem for many, if not all, organizations," says Spencer.

Spencer recommends performing interdisciplinary concurrent, prebill, or retrospective quality review, with a "zealous and ongoing" program for education based on the findings.

Since every code requires a POA indicator, and current documentation practices produce variable and oftentimes ambiguous results, it may be impractical to query for all conditions or diagnoses in question. "Thus, there is a chance that an 'N' may be assigned to a condition that was in fact present at the time of admission," says Spencer.

To address this, perform prebill review of all "N" responses, and if that is not feasible, do a retrospective review of all "Ns," advises Spencer.

There also is a risk of assigning a diagnosis or condition as a "Y" (POA) when in fact, if documentation was more clear and specific, it would have been answered as an "N" or "U" and submitted to the physician for a query.

Capturing these "missed opportunity" cases for retrospective audit is important, to ensure administrative-coded data are submitted with high levels of data integrity, says Spencer.

"Our greatest challenge for reporting these conditions is having complete and accurate documentation in the medical record, specifically around pressure ulcers," reports Dougherty.

The problem is that a thorough skin assessment is not routinely completed or incorporated into the physician routine physical examination; yet it is for nursing. "If nursing identifies the presence of a pressure ulcer, the physician is reluctant to document this because they did not actually visualize the pressure ulcer," Dougherty explains.

Currently, nursing and clinical documentation specialists interact with physicians by providing either verbal or written prompts. "A solution being considered is photographing the affected area and placing the picture on the chart for the physician to take into account when documenting," says Dougherty.

To address this, some facilities are requiring a skin assessment as part of the H&P, and others are requiring the physician to review and sign off on the wound care nursing note. "For this reason, the nursing documentation and wound care documentation is becoming more sophisticated to support accurate POA assignment," says Spencer.

Another problem is that urinary tract infections may not necessarily meet the Centers for Disease Control and Prevention's definition, yet if one is documented by the physician, physician's assistant, or nurse practitioner, it is coded as such.

"This is an educational issue, and one that we have involved multiple disciplines for input," says Dougherty. Clinical documentation specialists have designed educational posters for display in the medical staff lounge, and presentations on POA are delivered at scheduled staff meetings.

Also, when the source for a bacterium on a patient is unclear, physicians may arbitrarily assign it to the vascular catheter. "If a physician attributes the presence of an infection to the vascular catheter, it is coded as such, regardless if the link is confirmed," says Dougherty. As a result, it gets identified as a vascular catheter-associated infection, which may or may not be accurate.

"The physician has made that link based on his or her clinical judgment, regardless of what the lab indicated," says Spencer.

The coder cannot make that link without the physician documentation, but the infection control nurse may be able to assist when cultures have a contaminate. "This type of documentation issue is best handled by a clinical pertinence peer review — another physician reviewing the record — as coders do not typically query once documentation is present in the record," says Spencer.

[For more information, contact:

Cindy Dougherty, RN, CPHQ, Director, Quality Measurement & Improvement, Northwest Community Hospital, 800 W. Central Rd., Arlington Heights, IL 60005. Phone: (847) 618-4360. E-mail:

Sharon Kostroski, Vice President, Quality and Safety, St. Joseph's Hospital, Marshfield, WI 54449. Phone: (715) 387 7220. E-mail:

Carol Spencer, RHIA, Manager, Professional Practice Resources, American Health Information Management Association, 233 N. Michigan Ave., 21st Floor, Chicago, IL 60601-5800. Phone: (312) 233-1586. Fax: (312) 276-8448. E-mail:]