POA – Present on Admission

1. POA – Present on Admission Presented by Laurie Burckhardt EDI Manager

2. Agenda • Background of POA • Implementation dates • How to submit • CMS instructions • Open discussions

3. Background • Deficit Reduction Act (DRA) - signed February 2006 • Initial notification required the Present on Admission (POA) indicator to be collected for Medicare patients beginning Oct 1, 2007. A subsequent announcement modified the target date to January 1, 2008. [link required] • Requires CMS to select 2 or more infectious complications that are high cost/high volume to focus on. • Requires CMS to begin excluding those infections when they are identified as not present on admission from the calculation of the DRG beginning October 1,2008.

4. CMS Implementation Dates • 10/1/2007 – Hospitals should begin reporting the POA code for acute care inpatient PPS discharges” on or after 10/1/2007 (except for DDE). Information not used for claims adjudication • 1/1/2008 – Claims submitted with discharge dates on or after this date with no POA Indicators will continue to process, but the remittance advice will contain a remark code indicating the need for POA indicators. • 4/1/2008 – Claims submitted with discharge dates on or after this date with no POA indicators will be returned to the provider for correct submission of the POA information. • 10/1/2008 – Effective for acute care inpatient PPS discharges on or after this date, CMS cannot assign cases with these conditions to a higher paying DRG unless they were present on admission.

5. Other Health Plan Implementation Dates • At this time could find no other health plan that will require POA • WHAIC website has the following: • 5/17/07 Update: Although CMS will ‘require’ POA as of 10/1/07 WHAIC will not require POA until 1/1/08. CMS will not edit for POA until 4/1/08. CMS will send remarks on records without POA during the first quarter of 2008. WHAIC will allow POA as of 7/1/07.

6. Electronic Submission • 4010A1 has no means of submitting POA information, • The POA must be reported in K3 segment in the 2300 loop, data element K301 • Positions 1-3= POA, • Position 4= the POA indicator for the principal dx code. • Position 5 begins the reporting of POA indicators for all other dx codes if applicable. • A “Z” or an “X” must be reported to indicate the end of reporting of the POA indicators for the “other” dx codes. • The byte following the “Z” or “X” value represents the POA indicator for a submitted e-code if applicable. If the segment ends in a “Z” or an “X” value, than the e-code was not submitted. • Values for each byte are: • Y = Yes • N = No • U = unknown • W = clinically undetermined. • 1- Represents a space or blank and means the dx code is exempt from reporting of POA. • Z- Indicates the end of reporting of POA indicators for the other dx codes. • X- Indicates the end of reporting of POA indicators for the other dx codes when there are special processing situations.

7. Electronic claim examples • Examples: • K3*POAYNU1Z1~ No exception handling, e-code submitted. • K3*POA1YNU1Z~ No exception handling, no e-code submitted. • K3*POAYNU1XY~ Exception handling, e-code submitted. • K3*POA1YNU1X~ Exception handling, no e-code submitted.

8. UB04 Paper instructions • Form locator 67 Principal Diagnosis Code and Present on Admission Indicator • Present on Admission [POA] Indicator • The eighth digit of FL67 – Principal Diagnosis and each of the secondary diagnosis fields FL 67A-Q. • The eighth digit of FL 72 – External Cause of Injury [ECI] (3 fields on the form).

9. UB04 Usage instructions • The POA Indicator applies to the diagnosis codes for claims involving inpatient admissions to general acute-care hospitals or other facilities, as required by law or regulation for public health reporting. • The POA Indicator is based not only on the conditions known at the time of admission, but also include those conditions that were clearly present, but not diagnosed, until after the admission took place. • Present on admission is defined as present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, are considered as present on admission. • The POA Indicator is applied to the principal diagnosis as well as all secondary diagnoses that are reported.

10. UB04 usage instructions cont. • The five reporting options for all diagnosis reporting are as follows: Y Yes N No U No Information in the Record W Clinically Undetermined (Unreported/Not Used) Exempt from POA Reporting

11. Provider • Assumptions: • Assumes that the coders have all the information necessary to code the claims appropriately. • Must void and then replace the claim if they don’t get it right the first time • Requirements: • Will require education of the physicians, coders don’t want to take it directly out of the discharge summary – some docs aren’t too good at this

12. Provider Challenges • Physician doesn’t catch something in the ER. • Implementation issues • Time consuming & may hold up billing • What do the values actually mean? How will they be applied equally across the industry? • U = unknown • W = clinically undetermined. • Represents a space or blank and means the dx code is exempt from reporting of POA. • ICD-9 guidelines are inconsistent in identifying whether or not a condition was present or not on admission, Provided by WEDI Business Issues workgroup’s white paper

13. Questions to consider • How did they determine the POA was the appropriate mechanism for helping to gather the information they needed? Would it have been easier to go to a new version of the transactions for this rather than workarounds within the existing transactions? • Why are we doing this for one payer? Is this true administrative simplification? Using the POA on a claim for just them? Would we have done this for any other payer? How can we stop this type of mandate in the future? • Was a cost benefit analysis for the additional coding time needed done? If so, is it available for review? If not, why? Provided by WEDI Business Issues workgroup’s white paper

14. Concerns to be considered • Does this mean that a hospital will need to test for every possible infection that could be in the populations? Will this actually increase the cost of care as hospitals begin to cover themselves?? • Result in changing process and procedures and ultimately reimbursement. There is a big question about who will want the data. • Systems are NOT in place that can move the data from the medical record data capture to the billing system. Currently, free form fields are being used to move the data. This is a concern. • Providers are still working on NPI, many have not looked at these requirements. Provided by WEDI Business Issues workgroup’s white paper

15. CMS instructions • MLN Matters Number: MM5499 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5499.pdf • POA can begin to be reported as of 10/1/2007 with exception of DDE • Effective 1/1/2008 a new remark code will appear on remittance if POA is not given • Effective 4/1/2008 claims will be returned if POA is missing

16. Questions? Laurie.Burckhardt@wpsic.com