Documents to capture POA Indicators in Inpatient reports/charts
Coders can use several documents to decipher POA information:
1. ED notes: ED notes may state the patient’s condition in the workup.
2. History and physical (H&P): A patient’s condition may be diagnosed or found in the workup of the H&P portion of the physician exam notes. Past medical history, as well as current medications, may be found here as well.
3. Progress notes: Progress notes are a follow-up on a patient’s initial condition diagnosis. These notes may also reveal new fi ndings of existing conditions.
4. Consults: Reports from a consulting physician may yield information for management of other conditions that need surgery.
5. Admission forms: A nursing admission, an operating room admission, or an anesthesia workup may contain useful POA information.
6. Laboratory and x-ray reports: Coders can look for information in the workup of both laboratory and x-ray reports.
Coders should remember that admission forms, lab reports, and x-ray reports don’t support a POA indicator. To assign POA, coders must rely on a treating physician’s documentation.
Assuming physician documentation is accurate and complete, a coder can consider these tips when assigning the POA indicator:
· Look in the history and physical, as well as the emergency room physician documentation and admitting progress note and orders. The cut-off point in determining whether the condition was POA, is when the admit order was written.
· Look for confi rming diagnoses. Perhaps the physician documented a sign or symptom on admission, but didn’t render a diagnosis until two or three days later. The physician may have documented a diagnosis as “possible” or “probable,” but didn’t confi rm it until later in the progress notes. Only code a diagnosis listed as “possible” or “probable” if the condition is later confi rmed or still qualifi ed as uncertain at the time of discharge. Since the diagnosis is based on signs or symptoms that were POA, the coder would assign a “yes” indicator. Note that an uncertain diagnosis would be POA only when that diagnosis had related signs or symptoms that were present at the time of admission. Otherwise, if the signs and symptoms developed after the physician order, the diagnosis is not POA.
