Requirement of The POA Indicators

POA indicators is an alpha character assigned to the principal diagnosis code and any secondary diagnosis codes reported for each inpatient admission.

POA indicators are distinct from diagnosis codes and are not part of ICD 10 CM codes. Yes, they are assigned and reported to diagnosis codes, but they are different from diagnosis codes. Once the codes and POA indicator are entered, the POA indicator appears in a different data field on the claims form, separate from the ICD-10-CM diagnosis codes.

The main purpose for assigning and reporting POA indicators to ICD 10 CM diagnosis is to enable user to differentiate between diagnoses that were present on patient admission and diagnoses that developed after admission.

In Inpatient coding, new  ICD 10 PCS codes are used for reporting procedures. These codes come along with ICD 10  CM. In these set of codes, a list of root operation is given. These root of operation helps in selecting the correct ICD 10 PCS code. Below you can get more information on root of operation.

Coding tips for Root Operation EXCISION

Coding guide for Root Operation DRAINAGE

When to use Root Operation DILATION

Root Operation RESECTION Coding tips

What is Present on Admission (POA)?

As per ICD 10 CM guidelines, the present of admission is defined as the conditions present at the time the order for inpatient admission occurs. These condition will includes also the diagnosis that develop during an outpatient encounter which lead to an admission. Even the conditions present in during in the emergency department, in observation status or in the outpatient surgery.

When there in no clear documentation for whether a condition was present on admission or not, the coder should always query the provider or physician for Clarification. There are situations where their provider needs more information which were not present at the time of discharge to determine if a conditions was POA.

If the provide clearly document that the condition was present on admission, the POA indicator Y should be assigned.

Read also: Coding tips for CPT code 36901 for AV fistula Access

POA (Present on Admission) Indicators

Guidelines of POA indicator is given in Appendix 1 of the official guidelines for coding and reporting.

POA guidelines are not used to give information on when a condition should be coded, these guidelines only guide us in assigning or applying POA indicators to the final set of diagnosis codes. 

Their are four (4) POA indicator options. 

Yes (Y)                The condition was present at the time of inpatient admission.

No (N)                The condition was not present at the time of inpatient admission.

Unknown (U)   Documentation is insufficient to determine if condition is present on admission.

Clinically Undetermined (W)    The provider was unable to clinically determine whether the condition was present on admission.