'Present on admission' rule effective Jan. 2008

Access has role to play

By Jeffrey Smith, Manager, Provider Administration, Accenture, New York City

More than likely, patient access managers have recently heard the term "diagnoses present on admission" discussed by their health information management (HIM) and patient accounting colleagues.

These discussions refer to the Jan. 1, 2008, Centers for Medicare & Medicaid Services (CMS) requirement for completing a present on admission (POA) indicator for primary and secondary diagnoses on inpatient acute care claims. This indicator (Y-yes, N-no, U-unknown, W-clinically undetermined) will denote whether at the time the admission order was placed, the patient had a particular diagnosis.

Certain conditions and external causes of injury are exempt from POA reporting. A listing of these codes is found in Appendix 1 of the ICD-9 CM official guidelines for coding and reporting. The POA indicator should be captured by HIM staff after their review of clinical documentation associated with the patient's admission.

Although patient access staff do not have a direct role in obtaining this information, it is important for them to be cognizant of this legislation. The impetus for CMS to institute this legislation is to determine whether specific diagnoses attributable to preventable infections and injuries (indicative of quality of care) occurred during the course of the hospital stay.

In fiscal year 2009, CMS will reduce DRG (diagnosis-related group) reimbursement in instances where these diagnoses were not present on admission. Given the operational and financial implications of the POA requirement, it is important for patient access managers to be aware of this issue and to support diagnosis delineation whenever possible.

Diagnosis delineation integral

The present on admission requirement arises from Section 5001 (c) of the Deficit Reduction Act of 2005. This legislation requires CMS to identify conditions or diagnoses that meet these criteria:

  • high cost, high volume (or both);
  • result in the assignment of a DRG with a higher payment when present as a secondary diagnosis;
  • could have been reasonably prevented through the use of evidence-based guidelines.

Conditions meeting the above criteria include serious preventable events (air embolism, object left in during surgery, blood incompatibility), catheter infections, mediastinitis following coronary bypass surgery, and hospital-acquired injuries. As of Oct. 1, 2008, CMS will not assign claims with these conditions to a higher-paying DRG unless the condition or diagnosis was present on admission.

The term "present on admission" is defined as a condition the patient possesses at the time the decision for admission is made. Conditions arising during an outpatient encounter (emergency department, observation, outpatient surgery) will be considered as meeting the POA criteria. Documentation from any health care provider treating the patient can be utilized in determining the POA indicator.

Examples of source documentation include, but are not limited to: history and physical, physician orders, discharge summary, mid-level provider notes, nursing records (i.e. ante-partum notes), anesthesia records, consultation notes, and pathology reports. If any ambiguities or inconsistencies exist in the documentation, it is the responsibility of the coding staff to query the treating physician, asking for clarification.

Patient access staff can support the determination of POA by asking follow-up questions when appropriate to clarify underlying conditions of registration or scheduling.

That would include, for example, noting any underlying falls or injuries that occurred just prior to the time of admission. This is especially important in instances of multiple traumas, where underlying injuries may not be noted for several days after admission.

It is also important for registration staff to correctly note reasons for patient admission when specified, as these conditions can obviously be noted as being present on admission. Appropriately capturing admitting diagnosis information will assist HIM in examining the record further to determine whether a diagnosis was pre-existing or not.

In instances in which concurrent coding or updating of diagnoses is taking place (such as involvement of case management, utilization review, or clinical documentation specialists), paying attention to whether an underlying complaint was noted at the time of registration could assist these individuals in approaching a physician about whether a diagnosis was present at the time of admission.

Correctly determining whether a diagnosis was present on admission will be a challenge for both physicians and coding staff. Patient access leadership can facilitate this process by making sure registration staff are diligent in noting injuries and admitting complaints.

Patient access managers and directors can remind physicians the POA indicator is a CMS requirement and proper capture of these data will ensure hospital quality indicators are reported correctly.

(Editor's note: Jeffrey Smith specializes in revenue cycle transformation and system implementation/integration in Accenture's health provider practice. He can be reached at j.a.smith@accenture.com.)