Present on Admission (POA) codes
A Present on Admission (POA) code is assigned to each diagnosis code to indicate if the patient presented with that condition or not. This helps identify conditions that arose during the hospitalization and is used in determining adverse events, Patient Safety Indicators (PSIs) and Hospital Acquired Conditions (HACs), among other things. Some diagnosis codes are Exempt (1 or E) from this indicator, such as codes for chronic conditions. The POA codes for each diagnosis code on an encounter can be viewed in the Clinical Case Summary.
The following table defines the standard POA codes. For more information, see the CMS website.
| Code | Description |
|---|---|
| Y |
Diagnosis was present at time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator. |
| N |
Diagnosis was not present at time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator. |
| U |
Documentation insufficient to determine if the condition was present at the time of inpatient admission. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator. |
| W |
Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator. |
| 1 /E |
Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "1" for the POA Indicator. The “1” POA Indicator should not be applied to any codes on the HAC list. For a complete list of codes on the POA exempt list, see the CMS website. |
