Reference no: EM133757601

Question

In healthcare documentation and coding, accurately identifying conditions on admission (POA) is critical for proper patient management and reimbursement. A typical scenario is whether it is appropriate to query the physician regarding the presence of a pressure ulcer on admission if it is not documented until later during the patient's inpatient stay. When a condition like a pressure ulcer is not documented upon admission but appears later, it's crucial to query the physician. The Centers for Medicare & Medicaid Services guidelines recommend this for clarity and specificity, essential for accurate documentation and coding. The query process is a significant part of this. It prompts the physician to review the patient's history, physical examination, and other relevant clinical findings that might indicate the presence of the pressure ulcer at admission. The distinction between an Admission condition and a Hospital-Acquired Condition is significant. A POA condition that is present at the time the order for inpatient admission occurs, even if it is not immediately documented. Conversely, a HAC is a condition that develops during the hospital stay and is not present on admission. CMS has identified specific conditions that, if acquired in the hospital, can lead to reduced reimbursement under the Hospital-Acquired.