Data Quality and Query for Present on Admission
A patient is admitted with pneumonia. On admission, the patient has a stage 2 pressure ulcer on the sacrum. The nursing admission assessment documents the ulcer as present on admission. The physician's admission note does not mention the ulcer. The hospital's policy requires that pressure ulcers be documented by the physician to be coded as present on admission (POA). The coder reviews the record and sees the nursing documentation. The coder also notes that the physician documented 'skin intact' in the admission note. The coder is tasked with assigning POA indicators for the pressure ulcer (L89.152).
1. What POA indicator should be assigned? Explain the rationale and any query needed.
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The POA indicator should be 'Y' if the pressure ulcer was present on admission. However, there is conflicting documentation: nursing notes indicate the ulcer was present on admission, but the physician's admission note says 'skin intact.' The ICD-10-CM Official Guidelines for Coding and Reporting (Section I.B.13) state that for POA, the coder should use the documentation from the physician. If the physician does not document the pressure ulcer as present on admission, the coder cannot assume it was POA based on nursing notes alone. The coder should query the physician to clarify whether the pressure ulcer was present on admission. If the physician confirms, then assign 'Y'. If not, assign 'N' (not present on admission) or 'U' (unknown) if documentation is insufficient. The coder should also consider that 'skin intact' contradicts the nursing assessment. A query is necessary to resolve the discrepancy. The query should ask the physician to document whether the pressure ulcer was present on admission and to amend the note if appropriate.
2. How does this affect the hospital's quality reporting and reimbursement?
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The POA indicator affects the hospital's quality reporting and reimbursement under Medicare's Hospital-Acquired Condition (HAC) program and the Inpatient Prospective Payment System (IPPS). If a pressure ulcer is not present on admission (POA=N), it is considered a hospital-acquired condition and may not be reimbursed at a higher rate. Specifically, stage 3 and 4 pressure ulcers are HACs, but stage 2 is not currently a HAC. However, accurate POA assignment is still important for quality reporting and risk adjustment. If the coder incorrectly assigns POA=Y when the ulcer was actually hospital-acquired, it could lead to inaccurate quality data and potential compliance issues. If POA=N, the hospital may not receive additional payment for the ulcer as a secondary diagnosis. Therefore, the coder must ensure accurate documentation and query when necessary.