Health record management, also known as patient record management, helps you keep a centralized database of healthcare providers up to date. The records contain everything relevant to the patient’s allergies, medical history, prescription history, pathology reports, demographic data, and other personal information, including POA indicators ie: Present on Admission Indicators. Thus, having a streamlined and incredibly effective patient record management process is crucial for healthcare professionals.
What is a POA Indicator?
The entire health record management process—including the precise collection and application of POA indicators—is somewhat complicated to guarantee that patients receive the appropriate care from doctors. POA indicators are important because they facilitate the differentiation of conditions that existed before admission from those that emerged during the patient’s hospital stay.
To put it in simple words POA indicator is the patient condition that is prevalent at the time order for inpatient admission occurs. It is essentially used to distinguish conditions present at the time of admission from those that were developed during inpatient admission.
Precise documentation of these metrics may have an effect on hospital quality assessments and payments. However, because it can be difficult to determine and document whether a condition was present at the time of admission, the process might be complicated. An expert healthcare BPO partner can guarantee that all patient records, including POA indicators, are kept up to date and are stored in a way that makes them easily retrievable. This may be achieved by outsourcing patient record management to them.
Why is a POA Indicator Required?
With the aid of a POA indicator, the correct diagnosis-related groups are assigned to inpatient claims.
It is essential for providers to capture accurate Present on Admission (POA) indicators for all diagnoses submitted on Medicare inpatient acute care claims. But is it being captured correctly? “No,” as per experts. In fact, as per then, this is one of those areas that is marred by inefficiencies, vowing for a variety of reasons.
Key Performance Indicators (KPIs) play a crucial role in business success, so it’s important to understand their purpose and how to measure them accurately. With this in mind, we have compiled essential information about KPI indicators to help you get started.
What are POA Indicators Reporting Options?
Four main options are available while reporting POA indicators. These include “Y” and “N,” which denote whether the condition was present or not, respectively. The other option, “U,” is employed when the documentation does not provide clear indications as to whether a particular condition was present at admission. Finally, the “W” option is assigned when providers are unable to clinically determine whether a condition was present on admission.
How to Ensure that Accurate POA Indicators are Used?
Assigning accurate POA indicators is not the sole responsibility of a coder. In fact, according to official ICD-11 guidelines, assigning accurate indicators should involve a joint effort between the healthcare provider and the coding department. When such a combined process is in place, accurate code assignments can be made when reporting diagnosis, and as a result, claims can be speedily processed. The best practice that coders should employ when documentation is insufficient or clear enough is to send queries to healthcare providers. Ideally, companies that handle claims in bulk should also follow this practice of querying healthcare providers.
Examples of When to Assign “Y” or “N” POA Indicator Option
Assigning a “Y” for POA happens when there are documents to support the condition and in cases of chronic conditions such as leukemia. It is also applied in diagnoses such as cancer which happen afterwards based on conditions such nausea and vomiting that are present at admission. However, exacerbations of COPD which happen post admission should be marked as “N” and often complications arising from pregnancy will also be assigned the same value.
Detailed explanation of when to assign “Y” and “N” POA Indicators, as reported by AAPC:
- Any condition the provider unquestionably documents as POA: Y
- A condition the provider unquestionably documents as not being POA: N
- Conditions diagnosed prior to the admission, such as chronic conditions: Y
- The final diagnosis contains possible, probable, suspected, or rule-out at the time of discharge but was not suspected on admission: N
- Conditions diagnosed during the admission that were clearly POA, but diagnosed post admission (e.g., admitted with intractable abdominal pain, nausea/vomiting and melena, final diagnosis is stomach cancer): Y
- The final diagnosis contains an impending/threatened diagnosis but was not suspected on admission: N
- Conditions that develop during an outpatient encounter prior to a written order for inpatient admission: Y
- Scenarios where a combination code is assigned, and any part of the code was not POA (e.g. acute exacerbation of COPD, in which the exacerbation occurs post-admission): N
- A newborn condition present at birth, developing in utero, or occurring during delivery (e.g. meconium aspiration): Y
- A pregnancy/obstetrical complication not POA (e.g. laceration during delivery): N
- Scenarios where a single code identifies the chronic condition only and not the acute exacerbation (e.g. acute exacerbation of chronic leukemia): Y
- A condition documented as possible, probable, suspected, or rule-out at the time of discharge, which was suspected upon admission: Y
How OutsourceRCM Can Help You?
We are a leading medical billing and coding company in the U.S. healthcare industry with over 15 years of experience dealing with POA indicators and end-to-end healthcare revenue cycles. Leveraging this experience, we can help you assign accurate POA indicators and ensure that you receive timely and accurate reimbursements.
One of the things that differentiates us from the rest is our usage of state-of-the-art Computer Assisted Coding (CAC) software. We use this software to process text recorded in patient registers and also identify Present on Admission indicators to ensure that relevant codes are used in documentation. Also, our team of 500+ AAPC-certified coders and superlative medical coding support provided from 8 global delivery centers needs a special mention.
Are you prepared to enhance your revenue cycle management and guarantee the precision of your POA indicators? Give us a call right now, and our professionals will walk you through the steps. Together, let’s optimize your reimbursements and simplify your procedures.
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