POA at a Glance…

Present on Admission (POA) Indicator

  • An indicator that captures whether or not a diagnosis was present at the time of inpatient admission.
  • Applies to Inpatient Encounters
    • Principal diagnosis code
    • Secondary diagnosis code
    • E-Codes

POA Rationale

  • Timing is everything- When was the condition present?
    • Patient has a diagnosis of pneumonia. - If not POA, then hospital acquired?
    • Patient has a fracture of the hip. - If not POA, then hospital acquired?
    • Patient had surgery and has a fever. - If not POA, then hospital acquired?

POA Reporting Requirements

  • Is the condition present at the time the order for inpatient admission occurs?
  • Did the condition develop during an outpatient encounter including emergency department, observation and outpatient surgery prior to admission?
  • Issues related to inconsistent, missing, conflicting, or unclear documentation must by resolved by the provider.
Code * Translation Explanation
Y Yes Present at the time of inpatient admission
N No Not present at the time of inpatient admission
U Unknown Documentation is insufficient to determine if condition was present on admission
W Clinically undetermined Provider is clinically unable to determine if condition was present on admission or not
blank space Unreported/Exempt A list of ICD-9-CM codes will be published as exempt for this indicator

* POA Indicator Code

Download: The Case for the Present on Admission Indicator (HCUP)