Forum - Questions & Answers
Present on Admission status -- from a student working towards CPC
HELP! Anyone that can help me. Are there tools available or tricks for determining whether
a specific diagnosis was present on admission? An example: a patient is admitted for chemo.
Cant use tricks
You need to read the doctor's notes. If they did not document it then you cannot call it POA. Your hospital should be educating the docs on this and a system should be in place to cue the docs when a patient comes in with a foley or a bed sore to document it.
appreciate the input...
I am a student working toward my CPC, I know the rule about if it's not documented it didn't happen. I was just hoping for some input, ideas to help me retain the guidelines!
Help me understand
what you mean by "retain the guidelines". I don't know coding lingo.
"coding lingo"
since I am a student trying learn the general coding guidelines and specific coding guidelines.
That is the term that are used in the ICD9-CM book. I am just trying to build a network of fellow coders/billers to help me learn these details as I go. If I don't learn the guidelines now, it will be hard to get a job when I am finished with school!
POA Indicator
If the condition was present at the time the physician wrote the inpatient order, the indicator is Y. If not present, indicator is N. Documentation insufficient to determine, indictor is U. Provider unable to clinically determine, indicator is W. The hospital inpatient coder is required to be able to determine the correct status based upon physician documentation and append the correct POA indicator. Combination codes - all conditions described by the code must be present to use Y indicator.