Cracking the Code

Principal diagnosis with POA “N”

It is the responsibility of the inpatient coder to assign a Present on Admission (POA) Indicator for all principal and secondary diagnosis codes as defined in Section II of the Official Coding Guidelines. The “Y” indicator is for when a diagnosis is present at the time admission while the “N” indicator is for when a diagnosis is not present at the time of inpatient admission. The “U” indicator is for when documentation insufficient to determine if condition is present at the time of inpatient admission. Lastly, the “W” indicator is for when a provider is unable to clinically determine whether the condition was present at the time of inpatient admission.

According to the POA Reporting Guidelines, the coder should assign “N” if at least ONE part of the clinical concepts included in the code was NOT present on admission. This would also be appropriate for primary diagnoses. Here are a few examples of these instances below:

Alcohol dependence when withdrawal symptoms occur after admission

Chronic obstructive pulmonary disease when exacerbation occurs after admission

Gastric ulcer when bleeding occurs after admission

Asthma when asthmaticus occurs after admission

Duodenal ulcer when the perforation occurs after admission

 

Reference: AHA Coding Clinic Fourth Quarter 2016: Changes to the ICD-10-CM Official Guidelines for Coding and Reporting; Appendix I; Present on Admission Reporting Guidelines
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