Effective October 1, 2008
POA Reporting to Affect DRG Assignment

As directed in the federal Deficit Reduction Act (DRA) of 2005, the Centers for Medicare and Medicaid Services (CMS) requires many hospitals to report present on admission (POA) information on certain diagnoses on their Medicare claims.
The purpose of the POA reporting is to identify hospital-acquired conditions (HACs) that develop during the patient's inpatient admission. The DRA also requires an adjustment in Medicare Diagnosis Related Group (DRG) assignment for certain HACs.

Beginning October 1, 2007, CMS required Inpatient Prospective Payment System (IPPS) hospitals to submit POA information. Beginning April 1, 2008, CMS returned claims submitted for payment that do not contain proper reporting of POA information.

Effective with discharges on or after October 1, 2008, CMS and Tufts Health Plan Medicare Preferred will process POA information in the assignment of the DRG. Hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission, and the case will be paid as if the secondary diagnosis were not present. Tufts Medicare Preferred also will not provide additional payment for a condition if POA information required by CMS is not reported.

Additional Information
More information on POA reporting and the financial implications is available at the HAC & POA Indicator Reporting Web page at the CMS Web site.

• Who must report
  The POA Indicator requirement and Hospital-Acquired Conditions (HAC) payment provision only apply to Inpatient Prospective Payment Systems (IPPS) Hospitals. At this time, the following hospitals are exempt from the POA Indicator and HAC:
  • Critical Access Hospitals (CAHs)
  • Long-term Care Hospitals (LTCHs)
  • Maryland Waiver Hospitals
  • Cancer Hospitals
  • Children's Inpatient Facilities
  • Inpatient Rehabilitation Facilities (IRFs)
  • Psychiatric Hospitals


• Hospital-acquired conditions
  CMS selected conditions that are reasonably preventable by following evidence-based guidelines and that are either costly or common. Eight conditions were identified for POA reporting in 2007. Two additional conditions and an addition to one of the previous eight conditions were identified for reporting in FY 2009 beginning October 1, 2008.
  
  The 10 selected conditions include:
  1. Foreign object retained after surgery
  2. Air embolism
  3. Blood incompatibility
  4. Stage III and IV pressure ulcers
  5. Falls and trauma (fractures, dislocations, intracranial injuries, crushing injuries, burns, electric shock)
  6. Catheter-associated urinary tract infection (UTI)
  7. Vascular catheter-associated infection
  8. Surgical site infection after coronary artery bypass graft (CABG) and certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity
  9. Deep vein thrombosis (DVT)/pulmonary embolism (PE) following total knee replacement and hip replacement procedures
  10. Certain manifestations of poor control of blood sugar levels


• General reporting requirements
  • POA indicator reporting is mandatory for all claims involving inpatient admissions to general acute care hospitals or other facilities.
  • POA 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 POA.
  • A POA Indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an "other diagnosis."
  • Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider.
  • If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA Indicator would not be reported.


• POA indicator reporting options, definitions, and payment implications
  For electronic claims, Tufts Health Plan expects the POA indicator in the K3 segment of Loop 2300. Details can be found in our HIPAA 837 Claim Submission Companion Document. For paper claims, the following codes can be included with diagnoses in Box 67 of the UB-04 form:
  
  

  Code	Reason for Code
  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	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.