Which further clarification should be done regarding present on admission (POA) indicator of fall?

A patient was admitted for high fever and pain in umbilical region. During the second day of the hospital stay, the patient stood up to use the restroom and fell on the floor, resulting in a broken chin bone. A physician noted the fall on the second day in progress note.

Which further clarification should be done regarding present on admission (POA) indicator of fall?
A . No query is needed
B . Query physician for POA
C . Bring this case up in weekly Health Information Management meetings for further action
D . Take the case to physician advisor/champion to discuss further action

View Answer

Answer: B

Explanation:

A query should be generated to ask the physician for the POA indicator of the fall because the documentation is unclear whether the fall was present at the time of inpatient admission or not. The POA indicator is used to identify conditions that are present or not present at the time of admission, and has payment implications for certain hospital-acquired conditions (HACs). According to CMS, a fall resulting in trauma is one of the HACs that will not be paid at a higher rate if it is not present on admission. Therefore, it is important to clarify the POA indicator of the fall to ensure accurate coding and reimbursement. A query should be non-leading, concise, clear, relevant, and consistent with CDI standards and guidelines.

References:

CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)

Coding | CMS1

Present on Admission Indicators – Novitas Solutions2