Present on Admission Reportingcampus.ahima.org/audio/2007/RB020107.pdf · program. As a provider of...

© Copyright 2007 American Health Information Management Association. All rights reserved.

Present on Admission Reporting

Audio Seminar/Webinar February 1, 2007

Practical Tools for Seminar Learning

Disclaimer

AHIMA 2007 Audio Seminar Series i

The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. As a provider of continuing education, the American Health Information Management Association (AHIMA) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience:

1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation;

2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and

3) if the presentation will include discussion of investigational or unlabeled uses of a product.

The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with information from which they may make their own judgments.

Faculty

AHIMA 2007 Audio Seminar Series ii

Sue Bowman, RHIA, CCS

Sue Bowman has served as the Director of Coding Policy and Compliance for the American Health Information Management Association (AHIMA) since 1995. She earned a Bachelor of Science degree in Medical Record Administration from Daemen College in Amherst, New York. Prior to her current position, she held management positions in health information management and utilization review in an acute-care facility and provided consulting services to correctional and long-term care facilities.

Mrs. Bowman is responsible for AHIMA's policy initiatives related coding practice and fraud and abuse prevention, and serves as AHIMA's representative to the Cooperating Parties, a group that has direct input into the creation, maintenance, and updating of healthcare codes and guidelines for their use. She participates in the development of the official ICD-9-CM coding guidelines and the content of the American Hospital Association’s Coding Clinic for ICD-9-CM. Sue represents the Association at meetings of the ICD-9-CM Coordination and Maintenance Committee and the American Medical Association’s CPT Editorial Panel.

She has authored a book entitled “Health Information Management Compliance: A Model Program for Healthcare Organizations,” published by AHIMA. And, she has written numerous articles and provided a number of media interviews on fraud/abuse, compliance, and coding issues. Sue has also given a number of presentations on issues related to coding and compliance. Currently, she is actively involved in promoting adoption of ICD-10-CM and ICD-10-PCS as replacements for ICD-9-CM.

Nelly Leon-Chisen, RHIA

Nelly Leon-Chisen is the Director of the Coding and Classification at the American Hospital Association where she is responsible for leading the Central Office on ICD-9-CM. The Central Office, in cooperation with the National Center for Health Statistics (NCHS), the Centers for Medicare and Medicaid Services (CMS) and the American Health Information Management Association (AHIMA), serves as the authoritative source on ICD-9-CM relative to health care payment systems, statistical reporting, and health services research. She represents the AHA as one of the four ICD-9-CM Cooperating Parties. She is also the editor of Coding Clinic for ICD-9-CM and Coding Clinic for HCPCS.

Ms. Leon-Chisen has represented the AHA on other national groups such as the CPT-5 Project Advisory Group, Medicare Technical Advisory Group Outpatient Workgroup, ICD-10-PCS Technical Advisory Group, Panel to Evaluate the U.S. Standard Certificates, HEDIS Coding Users Panel, and ICD-9-CM Coordination and Maintenance Committee. She was co-chair of the Workgroup for Electronic Data Interchange (WEDI) ICD-10 Implementation Workgroup. She also serves as staff to the AHA representative to the CPT Editorial Panel. Nelly co-chaired the joint AHA-AHIMA ICD-10-CM Field Testing Project and was the technical lead for the AHA-AHIMA Facility Evaluation and Management (E/M) Code Development Expert Panel.

She has over 30 years experience in the health information management field including consulting, teaching, technical and management experience in hospital medical record departments. She is a Past President of the Chicago Area Health Information Management Association and a recipient of the Professional Achievement Award from the Illinois Health Information Management Association.

She has lectured extensively on coding, DRG and data quality issues throughout the United States and internationally. Nelly has also testified on behalf of the American Hospital Association at the National Committee on Vital and Health Statistics hearings on ICD-10-CM and ICD-10-PCS.

Table of Contents

AHIMA 2007 Audio Seminar Series

Disclaimer ..................................................................................................................... i Faculty .........................................................................................................................ii Present on Admission Indicator ....................................................................................... 1

UB-04 Implementation Timelines ......................................................................... 1 Electronic Claims ................................................................................................ 2 Why should you care?......................................................................................... 2 Deficit Reduction Act of 2006 .............................................................................. 3 Present on Admission History .............................................................................. 3 POA Advisory Workgroup .................................................................................... 4 Workgroup Initiatives ......................................................................................... 5 Reporting .......................................................................................................... 5

Present on Admission Guidelines ..................................................................................... 6 What the Guidelines are NOT .............................................................................. 7 Guidelines Steps................................................................................................. 7 Joint Effort Between Coder and Provider .............................................................. 8 Documentation................................................................................................... 8 Who is a Provider? ............................................................................................. 9 Polling Question #1 ...........................................................................................10

General Reporting Requirements ....................................................................................10 Definition..........................................................................................................11 What Diagnoses does POA Apply To? ..................................................................11 Reporting Options .............................................................................................12 “Exempt from Reporting” List .............................................................................12 Examples....................................................................................................13 POA Explicitly Documented.................................................................................13 Diagnosed prior to inpatient admission................................................................14 During admission but present before admission ...................................................14 Possible, Probable, Rule Out Differential Diagnosis ...............................................15 Polling Question #2 ...........................................................................................16 Develops during outpatient encounter prior to inpatient admission ........................16 Unclear Documentation......................................................................................17 Clinically Undetermined......................................................................................17 Chronic condition, acute exacerbation develop during admission ...........................18 Impending or Threatened Conditions ..................................................................18 Acute and Chronic Conditions .............................................................................19 Polling Question #3 ...........................................................................................20 Combination Codes............................................................................................20 Polling Question #4 ...........................................................................................21 Obstetrical Conditions ........................................................................................22 Polling Question #5 ...........................................................................................23 Perinatal Conditions...........................................................................................24 Congenital Conditions ........................................................................................24 External Cause of Injury.....................................................................................25

Resource/Reference List ................................................................................................26

Appendix ..................................................................................................................52 CE Certificate Instructions


AHIMA 2007 Audio Seminar Series 1

Notes/Comments/Questions

Present on Admission (POA) Indicator

New data element approved by the NUBCUB-04 Data Set and FormElectronic transaction 837 Institutional ClaimInitially will only apply to providers whose states require such reportingEffective date of UB-04: starting in March 1, 2007, to be completed by 5/23/07

1

UB-04 Implementation Timeframes

Adopted February 2005Implementation milestones• March 1, 2007

• Receivers (health plans, clearinghouses)

• March 1 – May 22, 2007• Submitters (health care providers (e.g.,

hospitals, skilled nursing facilities, hospice) can use either

• May 23, 2007 • All institutional paper claims must use UB-04

2




POA and Electronic Claims

POA has not yet been approved for use on ELECTRONIC claims.Current HIPAA version (004010/004010A1) of 837i claim does not accommodate POA.“X12 Reporting Guide” accommodates POA; but used for state data reporting, rather than claims.Workaround being developed.

3

Why should you care?

Mandated in some statesPotential for national implementation for Deficit Reduction Act (DRA) requirements for hospital acquired infectionsDRA requirement starting with discharges on or after 10/1/2007, affecting payment 10/1/2008.

4




Deficit Reduction Act of 2005

Passed December 2005Section 5001 Hospital Quality ImprovementReduces payments to hospitals in some cases when the patient acquires an infection during a hospital stay.Secretary is required to select at least two sets of two or more DRGs in which it is common for patients who otherwise would be assigned to a lower paying DRG to be assigned to the higher-paying DRG when there is a secondary diagnosis that results from infections acquired during the hospital stay.

5

Present on Admission History

1992: NCVHS UHDDS recommendation1996: NCVHS Core Health Data recommendation1999: Consultant proposes indicator for UB-922003: Consumer-Purchaser Disclosure Project proposed adding indicator to UB-02

6




Present on Admission History

2004: NCVHS Workgroup on Quality recommendation2004: NCVHS recommendation to HHS2005: MEDPAC Report to Congress2006: POA Advisory Workgroup2006: NUBC Approval of POA indicator for implementation in UB-04

7

POA Advisory Work Group

Agency for Healthcare Research and QualityAmerican Health Information Management AssociationAmerican Hospital AssociationBlue Cross/Blue ShieldCalifornia Office of Statewide Health Planning and Development

Consumer-Purchaser Disclosure ProjectIllinois Hospital AssociationNational Association of Health Data OrganizationsNational Center for Health StatisticsNCVHS Workgroup on QualityNUBC

8




POA Advisory Workgroup Initiatives

Review and comparison of state-specific and vendor definitions and guidelinesIdentification of special situations that should be addressed in reporting guidelinesIdentification of ICD-9-CM codes for which the indicator might be considered “not applicable”

9


States that have already implemented:• New York (1994)• California (1996)• Florida (1/07)• Maryland (1/07)• Massachusetts (1/07 )

States preparing to implement• Illinois (10/07)• Wisconsin (10/07) 10




POA Guidelines

POA guidelines have been published as part of ICD-9-CM Official Guidelines for Coding and Reporting(look for them also in Coding Clinic for ICD-9-CM)Developed by the ICD-9-CM Cooperating Parties

11

What the POA Guidelines Are:

Supplemental to the ICD-9-CM Official Guidelines for Coding and Reporting• Developed to facilitate the assignment

of the Present on Admission (POA) indicator for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837 Institutional).

12




What the POA Guidelines Are NOT:

• Not intended to replace any guidelines in the main body of the ICD-9-CM Official Guidelines for Coding and Reporting.

• Not intended to provide guidance on when a condition should be coded, but rather, how to apply the POA indicator to the final set of diagnosis codes.

13

POA Guidelines Steps

Assign ICD-9-CM diagnosis codes according to Sections I, II, and III of the official coding guidelines. Assign the POA indicator to those conditions that have been coded.

14




Joint Effort Between Coder and Provider

A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.

15

Documentation

The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission or not.

16




Documentation

Issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider.It is NOT necessary for the provider to explicitly document whether a condition is present on admission or not in order to appropriately assign the POA indicator.

17

Who is a Provider?

In the context of the official coding guidelines (including the POA guidelines), the term “provider”means a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.

18




Polling Question #1

Your hospital is not located in one of the states that have mandated POA reporting. Do you still need to be concerned about implementing the POA indicator at this time?

*1 Yes *2 No

19

General Reporting Requirements

All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information.

20




Definition

Present on admission is defined as present at the time the order for inpatient admission occurs -conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

21

What Diagnoses Does POA Apply To?

Principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) Includes External cause of injury codes (E-Codes)If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported

22




Reporting Options and Definitions

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 is present on admission)

W = Clinically undetermined (provider is unable to clinically determine whether condition was present on admission or not)

U = Unreported/Not used – (Exempt from POA reporting)

23

“Exempt From Reporting” List

Leave the “present on admission”field blank if the condition is on the list of ICD-9-CM codes for which this field is not applicable. This is the only circumstance in which the field may be left blank.

24




“Exempt” Reporting Example

137-139, Late effects of infectious and parasitic diseases650, Normal deliveryV03, Need for prophylactic vaccination and inoculation against bacterial diseasesV10, Personal history of malignant neoplasmV55, Attention to artificial openingsE800-E807, Railway accidents

25

POA Explicitly Documented

Assign Y for any condition the provider explicitly documents as being present on admission.Assign N for any condition the provider explicitly documents as not present at the time of admission.

26




Diagnosed prior to inpatient admission

Assign “Y” for conditions that were diagnosed prior to admissionExample: • hypertension, • diabetes mellitus, • asthma

27

Diagnosed during admission but clearly present before admission

Assign “Y” for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred • Example: Patient admitted for diagnostic

work-up for cachexia – final diagnosis is malignant neoplasm of lung with metastasis

28




Possible, Probable, Rule Out, Differential Diagnosis

If the final diagnosis contains a possible, probable, suspected, or rule out diagnosis, and this diagnosis was suspected at the time of inpatient admission, assign “Y.”

• Example: Patient admitted with chest pain, possible M.I. Final diagnosis is suspected acute M.I.

29

Possible, Probable, Rule Out, Differential Diagnosis (cont.)

If the inconclusive final diagnosis was based on symptoms or clinical findings that were not present on admission, assign “N.”

30




Polling Question #2

A patient undergoes surgery. After surgery, the patient develops fever and is treated aggressively. The physician’s final diagnosis documents “possible postoperative infection following surgery.”What would be the POA indicator for the diagnosis of postoperative infection?

*1 Yes *2 No

31

Develops during outpatient encounter prior to inpatient admission

Assign “Y” for any condition that develops during an outpatient encounter prior to a written order for inpatient admission • Examples:

• Atrial fibrillation develops after outpatient surgery and patient is subsequently admitted as an inpatient

• Observation patient falls out of bed and breaks a hip and is subsequently admitted as an inpatient to treat the hip fracture

32




Unclear Documentation

Assign “U” when the medical record documentation is unclear as to whether the condition was present on admission. “U” should not be routinely assigned but only used in very limited circumstances. Coders are encouraged to query the providers when the documentation is unclear.

33

Clinically Undetermined

Assign “W” when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was present on admission • Example: the provider is not able to

determine whether an infection developed after admission or was present at the time of admission.

34




Chronic condition with acute exacerbation developed during admission

If the code is a combination code that identifies both the chronic condition and the acute exacerbation, see POA guidelines pertaining to combination codes.

If the combination code only identifies the chronic condition and not the acute exacerbation (e.g., acute exacerbation of CHF), assign “Y.”

35

Impending or Threatened Conditions

Assign “Y” if the diagnosis is based on symptoms or clinical findings that were present on admission • Example:

A patient has a known history of coronary atherosclerosis, is status post myocardial infarction five years ago, and is now admitted for treatment of impending myocardial infarction. The final diagnosis is documented as “impending myocardial infarction.”

36




Impending or Threatened Conditions (cont.)

• Assign “N” if the diagnosis is based on symptoms or clinical findings that were not present on admission.

• Example: A patient is admitted to the hospital for prostate surgery. Postoperatively, the patient developed chest pain and the final diagnosis includes “impending myocardial infarction.”

37

Acute and Chronic Conditions

Assign “Y” for acute conditions that are present at time of admission and “N” for acute conditions that are not present at time of admission.

Assign “Y” for chronic conditions, even though the condition may not be diagnosed until after admission (e.g., lung cancer diagnosed during hospitalization)

If a single code identifies both an acute and chronic condition, see the POA guidelines for combination codes.

38




Polling Question #3

Patient with a known colostomy is admitted to the hospital for treatment of congestive heart failure. During the hospitalization, he develops an infection of the colostomy site. What should the POA indicator be for code 569.61, Infection of colostomy or enterostomy?

*1 Y*2 N*3 U*4 W

39

Combination Codes

Assign “N” if any part of the combination code was not present on admission (e.g., obstructive chronic bronchitis with acute exacerbation and the exacerbation was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission).Assign “Y” if all parts of the combination code were present on admission (e.g., patient with diabetic nephropathy is admitted with uncontrolled diabetes)

40




Combination Codes (cont.)

If the final diagnosis includes comparative or contrasting diagnoses, and both were present, or suspected, at the time of admission, assign “Y.”For infection codes that include the causal organism, assign “Y” if the infection (or signs of the infection) was present on admission, even though the culture results may not be known until after admission (e.g., patient is admitted with pneumonia and the provider documents pseudomonas as the causal organism a few days later.)

41

Polling Question #4

A patient was admitted to the hospital with traumatic injuries after a car accident. During the hospitalization, the patient began experiencing hemoptysis and an acute bleeding gastric ulcer was diagnosed. The documentation noted that this was a result of the patient self-medicating with large doses of aspirin for quite some time. The bleeding gastric ulcer is reported with code 531.00, Acute gastric ulcer with hemorrhage, without mention of obstruction. What should be the POA indicator for the bleeding gastric ulcer?

*1 Y*2 N*3 U*4 W 42




Obstetrical Conditions

Whether or not the patient delivers during the current hospitalization does not affect assignment of the POA indicator. The determining factor for POA assignment is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission or not.If the pregnancy complication or obstetrical condition was present on admission (e.g., patient admitted in preterm labor), assign “Y.”

43

Obstetrical Conditions (cont.)

If the pregnancy complication or obstetrical condition was not present on admission (e.g., 2nd degree laceration during delivery, postpartum hemorrhage that occurred during current hospitalization, fetal distress develops after admission), assign “N.”If the obstetrical code includes more than one diagnosis, and any of the diagnoses identified by the code were not present on admission, assign “N.”(e.g., Code 642.7x, Pre-eclampsia or eclampsia superimposed on pre-existing hypertension.)

44




Obstetrical Conditions (cont.)

If the obstetrical code includes information that is not a diagnosis, do not consider that information in the POA determination. Example: Code 652.1x, Breech or other malpresentation successfully converted to cephalic presentation should be reported as present on admission if the fetus was breech on admission but was converted to cephalic presentation after admission (since the conversion to cephalic presentation does not represent a diagnosis, the fact that the conversion occurred after admission has no bearing on the POA determination.)

45

Polling Question #5

Question: The patient presents to the emergency department with vaginal bleeding secondary to spontaneous abortion. She underwent aspiration dilation and curettage. However, the patient continued to bleed profusely postoperatively and was admitted as an inpatient for continued monitoring. The case is coded as 634.11, Spontaneous abortion, complicated by delayed or excessive hemorrhage. What is the appropriate POA indicator for this diagnosis?

*1 Y*2 N*3 U*4 W

46




Perinatal Conditions

Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered present at admission and should be assigned “Y.”This includes conditions that occur during delivery (e.g., injury during delivery, meconium aspiration, exposure to streptococcus B in the vaginal canal.)

47

Congenital Conditions and Anomalies

Assign “Y” for congenital conditions and anomalies. Congenital conditions are always considered present on admission.Examples: Congenital hydrocephalus, congenital absence of ear lobe, patent ductus arteriosus

48




External Cause of Injury Codes

Assign “Y” for any E code representing an external cause of injury or poisoning that occurred prior to inpatient admission (e.g., patient fell out of bed at home, patient fell out of bed in emergency room prior to admission.)Assign “N” for any E code representing an external cause of injury or poisoning that occurred during inpatient hospitalization (e.g., patient fell out of hospital bed during hospital stay, patient experienced an adverse reaction to a medication administered after inpatient admission.)

49

Resource/Reference List

• ICD-9-CM Official Guidelines for Coding andReporting

• AHA Coding Clinic for ICD-9-CM

50




Audience Questions

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Upcoming Audio Seminars

CPT: Surgery Coding Guidelines • February 8, 2007

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Appendix


CE Certificate Instructions

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AHIMA CE Certificate 2 AHIMA CEUs or 1.8 Nursing Contact Hours

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click on “Sign-in” then “Complete Online Evaluation”

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