Coding

To group diagnoses into the proper MS-DRG, CMS needs to identify a Present on Admission (POA) Indicator for all diagnoses reported on claims involving inpatient admissions to general acute care hospitals.  Use the UB-04 Data Specifications Manual and the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each "principal" diagnosis and "other" diagnoses codes reported on claim forms UB-04 and 837 Institutional. The Official Guidelines for Coding and Reporting for each fiscal year (FY) can be found in the comprehensive listing of ICD-10-CM files available under the Related Links section below

This web site is not intended to replace any guidelines in the main body of the ICD-10-CM Official Guidelines for Coding and Reporting.  The POA Indicator guidelines are not intended to provide guidance on when a condition should be coded, rather to provide guidance on how to apply the POA Indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines.  Subsequent to the assignment of the ICD-10-CM codes, the POA Indicator should be assigned to all diagnoses that have been coded.

As stated in the Introduction to the ICD-10-CM Official Guidelines for Coding and Reporting, 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. The importance of consistent, complete documentation in the medical record cannot be overemphasized.  Medical record documentation from any qualified healthcare practitioner who is legally accountable for establishing the patient's diagnosis.

The provider, a provider's billing office, third party billing agents and anyone else involved in the transmission of this data shall insure that any resequencing of diagnosis codes prior to transmission to CMS also includes a resequencing of the POA Indicators.

The Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule determined payment implications for each of the different POA Indicator reporting options.  To review the payment implications, see the CMS POA Indicator Options and Definitions table below. 

CMS POA Indicator Options and Definitions