POA

cmclose@saintfrancis.com

POA status still confuses me (new at this). If pt has hx of fever,
cough and CXR is done in ER and shows infiltrates or peribronchial
cuffing and dr doesn't write pneumonitis/pneumonia till day 2 of
admission, do I have to query for POA? Thank you for your help! Email
me: chutchinson@saintfrancis.com

Claudine Hutchinson RN
Clinical Documentation Improvement Coordinator
Children's Hospital at Saint Francis

david.smith

In that scenario, you will not need to get clarification on POA. The
diagnosis doesn't have to be made on admission, but the presentation,
symptoms, clinical indicators should be there to support that the
condition was POA.

Unknown

If it is not clear to you, query for POA.

Charlene

Unknown

No. The principle diagnosis is established after study. If the physician relates the pneumonitis or disease process to the signs and symptoms present on admission, you will not need to query. Our physicians here have finally learned for the most part to address the signs and symptoms to the diagnosis after study.



Juanita B. Seel RN
Supervisor Documentation Integrity
Greenville Memorial Hospital
Greenville, SC
864-455-4981

catladyrn

An exception to that, at least for me, is sepsis. The pt may look septic on admission, but if the physician doesn't write it for two days, they'll get a query from me. Right now I have an outstanding query because the physician initially wrote urosepsis and then changed it to sepsis due to UTI, and I'm asking if the systemic sepsis goes back to day 1 or if the UTI progressed to sepsis. If I don't, I know the coders won't take it as pdx.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

david.smith

I think it comes down to whatever your comfort level is +/- your facilities coding practices. For me, if a patient presented with all the s/s of sepsis and the doctor documents sepsis on day 2, I would capture that as POA. I would base that on the following POA guideline:

Diagnoses subsequently confirmed after admission are considered to be present on admission if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis OR constitutes an underlying cause of a symptom that is present at the time of admission.

When you get into the whole urosepsis v. sepsis scenario, we usually need a query just to get the documentation correct as to what the doctor's meaning is (UTI or Sepsis). Even in that case though, if the doctor goes from Urosepsis to Sepsis due to UTI in the first day or two then I would still take the sepsis as POA (assuming the patient met the clinical indicators for sepsis on admission). Unfortunately in a lot of my experience we have a different problem...the over documentation of sepsis.

dvitalone1

I agree with below!

catladyrn

The last line of my previous post is what says it all...if it isn't queried, the coders won't take it. (Except, of course, when they do!) We've also had coders who wouldn't take sepsis as POA when sepsis was first written LATER THAT DAY (such as by the ID consulting physician), even though the indicators were there all along. They insist on the three magic letters, POA. Not knowing which coder's going to get that chart, I have to be prepared for all contingencies, so generally I query for POA.

While I know the coding guidelines just fine, I also have received guidance in the past that coding sepsis POA without specific documentation that takes the diagnosis directly back to the time of admission is asking for trouble with auditors. So for me, better safe than sorry.

As to my current case, there were no SIRS indicators and the pt didn't look septic on admission, IMO; it looked like a UTI to me, so I didn't query it until they started writing sepsis and then I needed to get it straight.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

dvitalone1

Unfortunately it isn't black or white. I have just been given a chart the Medicare Quality Improvement Organization (QIO) is denying. Pt had a temp of 101.7 rectal in ER, apical 116, Wbc 17.37 which remained elevated, sed rate 57, documented systolics in the 90s, pt was described as lethargic and minimally responsive. Pt also had vague c/o abd pain. Foley placed in ER with a significant amount of urine returned. CXR showed interstitial infiltrates, UA showed 12 WBC. Given IV abx in ER. Per Pulmonary consultation "91yo who presents with sepsis likely from uti and wheezing due to bronchospasm. H&P states "possible early sepsis." Pt improved with IV fluids and IV abx. ID consultation states "sepsis syndrome" and "plan to cover pt broadly with IV abx." Multiple progress notes state uti/sepsis, except from ID which state "uti, sinusitis." Discharge summary states "possible early sepsis" under admission impression but under final diagnosis "acute sinusitis." DRG 871 was billed with PDx 038.9 but now the QIO wants to change it to DRG 689 stating pt does not meet clinical criteria for septicemia. Best of all, they want to change primary diagnosis to 590.8 pyelonephritis and this is NEVER mentioned anywhere in record! UGH!!!


Dawn M. Vitalone, RN
Clinical Documentation Improvement Specialist

dvitalone1

I also want to mention that I did query for Sepsis which primary did select and the query is part of permanent record!


Dawn M. Vitalone, RN
Clinical Documentation Improvement Specialist

cstukenberg

I hope you are sending them with the appeal the criteria for sepsis and all of the definitions that go with Sepsis, septic shock, sirs, severe sepsis, etc.

david.smith

Right...if it won't get coded/reported unless the coder "sees" a certain form of documentation then we are sort of caught between a rock and a hard place. Even if you may not technically need to query, you must in order to present the documentation in a way that will get it coded out most appropriately.
I also see a lot of what you are talking about in terms of "over documentation" with respect to sepsis. I think the providers are beginning to over compensate for the "urosepsis" issue by sometimes passing UTI and going directly to sepsis.
Yep, agree....if the patient isn't really showing a septic picture on admission and then progresses while in-house, then that is a perfect scenario for the query.

david.smith

Unfortunately they are going to try to deny anything and everything. It is up to the facility to appeal any and all cases that appear accurate from a documentation, clinical and coding perspective. I think may of the auditors (esp. RACs) are hope we won't have the resources or motivation to appeal the cases. In your case, that should be appealed through the highest level possible. If they can get away with that denial, then what can't they overturn!

lspryszak

This is a classic example of when a POA query will support the PDx. Coding Guidelines state that the provider must clearly indicate whether something is POA - one can not assume based on clinical findings: just because the culture or test was done at admission. If the diagnosis is not in the ED records, H/P, admitting orders or initial progress notes and the diagnosis is not documented until later in the stay, then the coder cannot assign a POA indicator of "Y" without clarification.

Although we tend to assume that something was POA based on clinical indicators, auditors are denying diagnoses based on when it was actually documented.

david.smith

The POA guidelines direct the coder to assign a POA of "Yes" in the following circumstance:

Diagnoses subsequently confirmed after admission are considered to be present on admission if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis OR constitutes an underlying cause of a symptom that is present at the time of admission.

If a patient has a clear symptom referable to the diagnosis which is confirmed after admission, then the POA indicator is yes by rule.

I believe the key word is "symptom", if the patient just as an abnormal lab test then the POA will need to be clarified. From my experience, it is usually the symptoms that cause them to present to the hospital but there definitely cases where an abnormal lab in the doctor's office can get them sent to the ER.