Present on Admission

1. Present on Admission

2. Requirements of Deficit Reduction Act 2005 • CMS and CDC choose conditions that are: High Cost, High Volume, or both. • Assigned to higher DRG when code present as secondary diagnosis. • Diagnoses are reasonably preventable. • Easily identifiable by unique ICD9 codes on the UB92(hospital bill).

3. FY 2008 IPPS Proposed Rule Beginning October 1, 2008 Codes representing certain conditions may not be considered during DRG assignment unless Present on Admission.

4. History of Present on Admission (POA) • Effective January 1, 2007 (Florida). • Already implemented: NY 1994, California 1996. • Requirement for all hospitals by October 1, 2007. • Will eventually be used by CMS for payment/reimbursement.

5. Intent of Present On Admission • Distinguish any pre-existing conditions, prior to the hospitalization from those conditions that developed during the current hospitalization. • Identify which conditions/complications are avoidable. • Reduce financial reimbursement by subtracting payment for conditions that developed during the hospitalization.

6. Present on Admission Overview • Intended to help distinguish between pre-existing conditions and those that developed, or were first recognized, during the hospitalization. • CMS will require hospitals to identify which secondary diagnoses were present on admission on their claim forms.

7. Definition of POA • Present at the time the order for inpatient admission occurs, including conditions that develop in the following areas that resulted in inpatient admission: • Outpatient Encounter • Emergency Department • Outpatient surgery • Includes conditions that were clearly present but not diagnosed until after admission.

8. POA Conditions • Hypertension • Diabetes Mellitus • Asthma • COPD • CHF • Any chronic condition, even if not diagnosed until after admission (i.e. liver biopsy chronic active hepatitis).

9. Exempt From POA • Critical Access hospitals • LTACH • Maryland Waiver Hospitals • Cancer Hospitals • Children’s Inpatient facilities • Hospitals paid differently than acute care hospital PPS system

10. POA Rationale • To measure hospital performance. • For public reporting. • To distinguish between pre-existing conditions and complications. • To improve reporting accuracy of hospital.

11. POA Rationale (cont’d) • Increase validity of hospital report cards related to quality of care. • Improve accuracy of results in mortality risk assessment and outcomes research.

12. Additional POA Conditions being Considered by CMS • Catheter associated UTI • Pressure ulcer • Object left in during surgery • Air embolism • Delivery of ABO incompatible blood products • Staph aureus septicemia

13. Additional POA Conditions being Considered by CMS (Cont’d) • Ventilator associated pneumonia • Vascular catheter associated disease • Methicillin resistant staph aureus infection • Surgical site infection • Surgery on wrong part, patient, or wrong surgery • Patient falls

14. Significant Implications of POA • Liability: If condition is not POA, presumed condition is “hospital acquired.” • Financial: May impact reimbursement. • Public Reporting: Negative data, hospital acquired infections/complications on CMS website.

15. Physician Concerns • Early documentation to support POA (documentation by any provider involved in care and RX, i.e., any physician, or qualified healthcare practitioner). • Clarify POA anywhere in medical record. • Respond timely to queries for clarification of diagnoses. • Make physician aware of impact of POA.

16. Hospital Preparation For POA Education: • Coders • Case Managers • Clinical Documentation Nurses • Physicians, Nurses, Allied Health, etc. • Admitting, Business Office

17. References CMS (Centers for Medicare and Medicaid Services) 2007.

18. Review Questions • What regulatory agency has enacted the Present on Admission legislature? • True or False: One of the intents for POA is to distinguish between any pre-existing conditions, prior to the hospitalization from those conditions that developed during the current hospitalization.

19. Review Questions • Name 2 conditions that are considered to be “hospital acquired” during the patient's hospitalization. • True or False: The CMS website will be publicly reporting the POA data in the future.

20. Answer Key • CMS • True • See slides with POA Conditions • True