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Present on Admission Indicators

Present on Admission (POA) was introduced on October 1, 2007 when Medicare began to require that hospitals code all diagnoses using POA indicators  to indicate whether a diagnosis was present at the time of the inpatient admission.

POA Indicators must be reported for both principal and secondary diagnosis codes.

There are five POA Indicator options:

Indicator

Explanation

Y

Yes — diagnosis was present at the time of the inpatient admission

N

No — diagnosis was not present at the time of the inpatient admission

U

Unknown — documentation is insufficient to determine if a condition or diagnosis was present at the time of the inpatient admission

W

Clinically Undetermined — provider is unable to clinically determine whether condition or diagnosis was present at the time of the inpatient admission

1

Exempt from POA reporting

The indicators can be found in fields 67A-Q on the Uniform Billing form.

If a claim is submitted with insufficient POA indicators, the claim will be denied with the code GO – Denied: invalid/blank POA billed.

For more information about The Present on Admission or to view a list of POA diagnoses, visit the CMS website at http://www.cms.gov/.

Additional Resources: