Decubitus POA

pmill@seormc.orgpmill@seormc.org
in CDI Talk Archive
I have a Dr.documenting in his H&P decubitus ulcer. Can it be coded as present on admission? I am being told that before the coder can code it as POA it has to state in his exact words decubitus ulcer present on admission. Does anyone have any information on this.


Thanks,

Pandora Miller RN, BSN,CCDS

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    If the diagnosis is in the H&P, its POA, Right? Does the coder expect the provider to write Present on admission for each diagnosis in the H&P? the decubitus should be treated like any other dx (in regards to POA) in my opinion.
    Am I missing something?

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • cynthia.a.goeweycynthia.a.goewey
    edited May 2016
    Hi Pandora,
    I am not sure how the coder would think there is a possibility the ulcer is acquired in the hospital when the H&P is the initial assessment. Our coders would code it as POA w/o further clarification. I am not sure why your coders would insist it would have to say POA. I just discussed with 2 of our coders and manager and they said they would code it.
    Cindy

  • kmckaigkmckaig
    edited May 2016
    You're kidding, right? How much clearer could it be? Our coders would take it without further clarification.


    Karen McKaig, BSN, RN, CCM, CPUR, CCDS
    Case Manager
    Clinical Documentation Specialist
    Baxter Regional Medical Center
    Mountain Home, AR 72653
    870-508-1499
    kmckaig@baxterregional.org

  • pmill@seormc.orgpmill@seormc.org
    edited May 2016
    No, your not missing anything. I was trying to say the same thing but thought maybe I was missing something.

    Thanks,

    Pandora

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    AHA (Coding Clinic) offers examples, - refer coding staff to 2008 4th
    quarter of Coding Clinic for more scenarios and examples


    ******************************************************************
    "1. Patient is admitted for diagnostic work-up for cachexia. The final
    diagnosis is malignant neoplasm of lung with metastasis.


    Assign "Y" on the POA field for the malignant neoplasm. The malignant
    neoplasm was clearly present on admission, although it was not diagnosed
    until after the admission occurred."

    10. A patient is admitted with high fever and pneumonia. The patient
    rapidly deteriorates and becomes septic. The discharge diagnosis lists
    sepsis and pneumonia. The documentation is unclear as to whether the
    sepsis was present on admission or developed shortly after admission.


    Query the physician as to whether the sepsis was present on admission,
    developed shortly after admission, or it cannot be clinically determined
    as to whether it was present on admission or not.


    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739

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