Question

of H. Questions: 1. When is POA reporting required? 2. List three types of facilities exempt from POA reporting. 3. How are conditions that develop in the outpatient area of the hospital before a patient becomes an inpatient reported for POA? 4. How does a facility handle conditions that are ambiguous as far as whether they are present on admission or not? 5. How does the presence of a hospital-acquired condition affect reimbursement? 6. Review the list of conditions that are identified as HACS at the following webpage: CMS List of HACS Evaluate the information, present and defend your opinion as to why you think Medicare has elected not to reimburse hospitals when a HAC has occurred based on Medicare's set of criteria. (Medicare Hospital-Acquired Condition Reduction Program) (A5)

Answer 1

1. A power of attorney (POA) is a legal document giving one person (the agent or attorney-in-fact) the power to act for another person (the principal). The agent can have broad legal authority or limited authority to make legal decisions about the principal's property, finances or medical care. The power of attorney is frequently used in the event of a principal's illness or disability, or when the principal can't be present to sign necessary legal documents for financial transactions.

A power of attorney can end for a number of reasons, such as when the principal dies, the principal revokes it, a court invalidates it, the principal divorces his/her spouse who happens to be the agent or the agent can no longer carry out the outlined responsibilities.

Conventional POAs lapse when the creator becomes incapacitated, but a “durable POA” remains in force to enable the agent to manage the creator’s affairs, and a “springing POA” comes into effect only if and when the creator of the POA becomes incapacitated. A medical or healthcare POA enables an agent to make medical decisions on behalf of an incapacitated person.

• A power of attorney (POA) is a legal document giving one person, the agent or attorney-in-fact the power to act for another person, the principal.
• The agent can have broad legal authority or limited authority to make decisions about the principal's property, finances or medical care.
• The power of attorney is often used when a principal becomes ill or disabled, or when they can't be present to sign necessary legal documents for financial transactions.

As required by Section 5001(c) of the DRA, by October 1, 2007, the Secretary of the Department of Health & Human Services was required to identify at least two conditions that:●Are high cost or high volume or both●Result in the assignment of a case to an MS-DRG that has a higher payment when present as a secondary diagnosis●Could reasonably have been prevented by applying evidence-based guidelinesFor discharges occurring on or after October 1, 2008, IPPS hospitals do not receive the higher payment for cases when one of the selected conditions is acquired during hospitalization (that is, the condition was not POA). The case is paid as though the secondary diagnosis is not present.The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and the ICD-10 Procedure Coding System codes included in the HAC payment provision for 2018 reporting are available online via zip file.Review the Final HAC List to find the categories and corresponding complication or comorbidity or major complication or comorbidity International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes in the HAC payment provision.

Valid POA Codes

• Y = present at time of order to admit
• N = not present at time of order to admit
• U = insufficient documentation to determine if Y or N
• W = provider unable to determine if Y or N
• blank = diagnosis exempt from POA reporting

General Reporting Requirements

This list provides some POA general reporting requirements:

• Include the POA indicator on all claims that involve Medicare inpatient admissions to general IPPS acute care hospitals or other facilities, and you are subject to a law or regulation that mandates the collection of POA indicator information.
• POA is defined as being present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter (including emergency department, observation, or outpatient surgery) are considered POA.
• Assign the POA indicator to principal and all secondary diagnoses as defined in Section II of the “Official Guidelines.”
• Resolve issues related to inconsistent, missing, conflicting, or unclear documentation.
• Do not report the POA indicator if a condition is not coded and reported based on Uniform Hospital Discharge Data Set definitions and current “Official Guidelines.”
• CMS does not require a POA indicator for the external cause of injury code unless you are reporting it as an “other diagnosis.”

2. At this time, the following hospitals are exempt from reporting the POA Indicator and the HAC payment provision:

1. Critical Access Hospitals (CAHs)
2. Long-term Care Hospitals (LTCHs)
3. Maryland Waiver Hospitals*
4. Cancer Hospitals
5. Children's Inpatient Facilities
6. Religious Non-Medical Health Care Institutions
7. Inpatient Psychiatric Hospitals
8. Inpatient Rehabilitation Facilities
9. Veterans Administration/Department of Defense Hospitals

3.

A RELOOK AT POA INDICATORS By Ginny Martin, RHIA, CCS Accurate assignment of the present on admission (POA) indicator has new significance with the inception of value-based purchasing (VBP). Coding and the supporting medical record documentation are being used to identify the hospital-acquired conditions and patient safety indicators on which hospital incentive payments are based, making it imperative that the POA indicator matches documentation in the record. With this new emphasis on the timing and quality of care, a review of the POA guidelines can be beneficial. POA Options and Definitions Whether coding in ICD-9-CM or ICD-10-CM, the POA indicator is assigned to the principal and secondary diagnosis codes on all inpatient admissions to acute care hospitals or other facilities that are subject to POA requirements. Following are the five options when reporting the POA indicator: Y – Yes, present at the time of inpatient admission N – No, not present at the time of inpatient admission U – Unknown, documentation is insufficient to determine if condition is present on admission W – Clinically undetermined, provider is unable to clinically determine whether condition was present on admission or not Unreported/Not used /Blank – Exempt from POA reporting The Admission Timeline For a diagnosis or condition to be considered present on admission it must be present at the time the order is written for inpatient admission. If a condition develops during an outpatient encounter and the patient is subsequently admitted to an inpatient status, that condition is considered present on admission. If a patient exhibits signs or symptoms of a condition that is not confirmed until after admission that condition is considered present on admission, if the provider documents a correlation. In addition, a final diagnosis documented as possible, probable, suspected, or rule out may be considered present on admission based on signs and symptoms present at the time the admission order was written. There is no specific timeframe in which a provider must indicate a condition is present on admission. If at any time documentation it is not clear whether a condition was present on admission, a query should be sent to the provider for clarification. Assigning the POA Indicator For combination codes, all conditions described within the code must be present on admission to assign a POA indicator of "Y." For example, esophageal varices that do not start bleeding until after admission must be assigned a POA of "N." This is true for both ICD-9-CM and ICD-10-CM. The POA indicator for obstetrical conditions is determined by whether the pregnancy complication was present on admission, not whether a delivery occurred. Antepartum conditions, such as pre-existing hypertension, hypothyroidism, and gestational diabetes, are usually considered present on admission and would have a POA indicator of "Y." All conditions that bring a patient to the hospital are assigned a POA indicator of Y. Those conditions that occur during or after delivery are not present on admission and should be assigned a POA indicator of "N." These may include perineal lacerations during delivery, postpartum hemorrhage, or retained placenta. Newborns are not considered admitted until after birth. Any conditions present at birth or that develop during the delivery or in utero are considered present on admission, including injuries during delivery and congenital conditions. External causes of injury codes are also assigned a POA indicator. For those codes describing a cause that occurred prior to an inpatient admission including incidents occurring in outpatient areas prior to the admission order being written are assigned a POA indicator of "Y." Any external cause code representing incidents occurring after the inpatient order is written is assigned an indicator of "N." POA #1 A patient presents to the emergency department with shortness of breath, swelling in the lower extremities, and productive cough. Chest x-ray shows pulmonary vascular changes, cardiomegaly and slight pleural effusions, and possible infiltrates or atelectasis. Lab results showed a B-type (BPN) natriuretic peptide of 900 and elevated white blood cells. The patient was given Lasix and Levaquin intravenously after the test results were received and then admitted to inpatient status with a diagnosis of acute on chronic systolic heart failure. The POA indicator for the heart failure would be "Y." POA #2 Using the patient from the first scenario, the coder identifies documentation by the provider of a possible infection. The patient presented with a cough and shortness of breath. There were also possible infiltrates on the chest x-ray on admission, the white blood cells were elevated, and the patient was started on IV Levaquin. After an appropriate query to the provider asking the significance of these clinical findings, the attending physician documents the findings as due to pneumonia. Because the physician correlated the signs and symptoms present on admission to a definitive diagnosis, the POA indicator for the pneumonia would be "Y" even though the diagnosis was not documented until after admission. Conclusion: Coding Professionals are the Experts Coding professionals are expected to abide by the AHIMA Standards of Ethical Coding. These standards include statements, not only on diagnosis and procedure codes, but on the use of POA indicators as well. External agencies such as the Centers for Medicare and Medicaid Services and The Joint Commission rely on the coded data to determine payment, quality measurements, and public reporting. The coding professional—the subject matter expert—is responsible for ensuring the reported data is accurate by remaining well-versed on coding rules and guidelines, as well as staying abreast of the changes and multiple ways the data is used, to ensure that data is used and interpreted appropriately. POA Code for Example A patient is admitted for a diagnostic work-up of severe cough and difficulty breathing The final diagnosis is malignant neoplasm of the middle lobe of the lung ICD-9-CM = 162.4; POA = Y Although the malignant neoplasm is not diagnosed until after admission, it is clearly present on admission During the recovery period after outpatient surgery, a patient develops atrial fibrillationand subsequently is admitted to the hospital as an inpatient During the recovery period after outpatient surgery, a patient develops atrial fibrillationand subsequently is admitted to the hospital as an inpatient ICD-9-CM = 427.31; POA = Y Atrial fibrillation develops prior to a written order for inpatient admission While being treated in Observation, a patient falls out of bed and breaks a hip The patient subsequently is admitted to the hospital as an inpatient with a closed transcervical fracture of the base of the neck of the femur. How does the presence of a hospital-acquired condition affect reimbursement? Hospitalist Neal Axon, MD, first became aware of an important change in his hospital’s policies last year while attending to an elderly patient the morning after admission to the community hospital where he works part time. “This new form appeared in the chart requesting a urinalysis for my patient, who’d had a Foley catheter placed,” says Dr. Axon, an assistant professor of medicine at the Medical University of South Carolina in Charleston. “I didn’t know why, so I asked. I was told that it was now necessary to document that there was no UTI present on admission.” He asked the charge nurse, “So what do I do now that the catheter has been in place for 12 hours and has colonization without a true infection?” The next thing he heard: silence. The new form Dr. Axon encountered was an outgrowth of the requirements of the Deficit Reduction Act (DRA) of 2005, which ordered Medicare to withhold additional hospital payments for hospital-acquired complications (HAC) developed during a hospital stay. One result of the new rule is that much of a hospital’s response to these initiatives has been placed in the hands of the hospitalist. From accurate documentation of complications already present on admission (POA), to confirming that guidelines for treatment are being followed, to taking the lead on review of staff practices and education, hospitalists are in a position to have a wide-ranging impact on patient care and the financial health of their institutions. Congress Pushes Reforms In order for Medicare to not provide a reimbursement, an HAC has to be high-cost and/or high-volume, result in the assignment of the case to a higher payment when present as a secondary diagnosis, and “could reasonably be prevented through the application of evidence-based guidelines,” says Barry Straube, MD, chief medical officer and director of the Office of Clinical Standards and Quality at the Centers for Medicare and Medicaid Services (CMS). “CMS was to implement a process where we would not pay the hospitals additional money for these complications.” The new rules mean Medicare pays hospitals on the basis of Medicare Severity Diagnostic-Related Groups (MS-DRG), which better reflect the complexity of a patient’s illness. The biggest change was a three-tiered payment schedule: a base level for the diagnosis, a second level adding money to reflect the presence of comorbidities and complications, and a third for major complications and comorbidities (see Table 1, p. 31). “Instituting HACs means that hospitals would no longer receive the comorbidity and complication payments if the only reason a case qualified for higher payment was the HAC,” Dr. Straube explains. “We did carve out a POA exception for those conditions that were acquired outside of the hospital. HACs only impact additional payments; the hospitals are still paid for the diagnosis that resulted in the hospital admission.” CMS also identifies three “never events” it won’t reimburse for (see “A Brief History of Never Events,” p. 35): performing the wrong procedure, performing a procedure on the wrong body part, and performing a procedure on the wrong patient. “Neither hospitals nor physicians that are involved in such egregious situations would be paid,” Dr. Straube says. CMS’ List of Hospital-Acquired Conditions Foreign object retained after surgery; Air embolism; Pressure ulcers; Blood incompatibility; Falls and trauma (fractures, dislocations, intracranial injury, crushing injury, burn, electric shock); Catheter-associated UTI; Vascular catheter-associated infection; Manifestations of poor blood-sugar control; Surgical-site infection following coronary artery bypass surgery; Surgical-site infection following orthopedic procedures; Surgical-site infection following bariatric surgery for obesity; DVT and PE following orthopedic procedures; and Ventilator-associated pneumonia. The big questions surrounding HACs: Could they reasonably be prevented through the application of evidence-based guidelines? How preventable are HACs? Who decides if a complication is preventable, and therefore payment for services is withheld? They’re concerns that are widespread among physicians, hospital administrators, and regulators alike. “The legislation required the conditions to be ‘reasonably preventable’ using established clinical guidelines,” Dr. Straube says. “We did not have to show 100% prevention. In an imperfect world, they might still take place occasionally, but with good medical care, almost all of these are preventable in this day and age.” For CMS, the preventable conditions are an either/or situation: Either they existed prior to admission and are subject to payment, or they did not exist at admission and additional payment for the complication will not be made. “HACs do not currently consider a patient’s individual risk for complications,” says Jennifer Meddings, MD, MSc, clinical lecturer and health researcher in the Department of Internal Medicine at the University of Michigan Health System in Ann Arbor. “We know the best strategies to prevent complications in ideal patients, and these are reflected in the HACs. In real life, many of our patients just don’t fit into the guidelines for many reasons—and you have to individualize care.” Dr. Meddings points to DVT as a prime example. For a certain number of inpatients, the guidelines can be followed to perfection. In other patients (e.g., those with kidney conditions), previous reactions to a medication or an individual’s predisposition to clotting might interfere with treatment. However, CMS doesn’t allow appeals of nonpayment decisions for HACs based on individual circumstances. Some experts think the rigidness of the payment policy forces physicians to treat patients exactly to guidelines. Even then, payment could be declined if an HAC develops. “One of the points of most discussion is how preventable some of these are, particularly when choosing those you are no longer going to pay for,” Dr. Meddings says. “Many of the complications currently under review have patients that are at higher risk than others. How much our prevention strategies can alleviate or reduce the risk varies widely among patients.” Impact on HM Practice Many of the preventable conditions outlined by CMS do not directly affect hospitalist payment. However, hospitalists often find themselves responsible for properly documenting admission and care. “The rule changes regarding payment for HACs are only related to hospital payments, and to date, most physicians, including hospitalists, are not directly at financial risk,” says Heidi Wald, MD, MSPH, hospitalist and assistant professor of medicine in the divisions of Health Care Policy Research and General Internal Medicine at the University of Colorado Denver School of Medicine. “Although hospitalists have no financial skin in the game, there are plenty of reasons they would take an interest in addressing HACs in their hospital. In particular, they are often seen as the ‘go-to’ group for quality improvement in their hospitals.” For example, some HM groups have been active in working with teams of physicians, nurses, and other healthcare providers to address local policies and procedures on prevention of catheter-associated urinary tract infections (UTIs) and DVT. Documentation Is Key Beyond applying proven methods to avoid HACs, hospitalists can make a difference through documentation. If the hospitalist notes all conditions when the patient first presents to the hospital, additional comorbidity and complication payments should be made. “The part that probably has the greatest impact on the day-to-day practice of a hospitalist is the increased importance of documentation throughout the hospital episode,” Dr. Meddings says. “If complications are occurring and they are not present in the chart, the coders may not recognize that it has occurred and will not know to include it in the bill. This can have an adverse impact on the hospital and its finances.” Documentation issues can impact hospital payment in several ways: Hospitals might receive additional payment by default if certain HACs are described incorrectly or without sufficient detail (e.g., receiving overpayment because the physician did not indicate a UTI was in fact a catheter-associated UTI); As more attention is invested in documenting all conditions POA, hospitals might be coding more comorbidities overall than previously, which also will generate additional payment for hospitals as any POA condition is eligible for increased payment; and Hospitals might lose payment when admitting providers fail to adequately document the condition as POA (e.g., a pre-existing decubitus ulcer not detected until the second day of the hospital stay). The descriptions to be used in coding are very detailed. UTIs, for example, have one code to document the POA assessment, another code to show that a UTI occurred, and a third code to indicate it was catheter-associated. Each code requires appropriate documentation in the chart (see Table 1, above). The impact hospitalists have on care and payment is not the same across the HAC spectrum. For instance, documenting the presence of pressure ulcers might be easier than distinguishing colonization from infection in those admitted with in-dwelling urinary catheters. Others, such as DVT or vascular catheter-associated infections, are rarely POA unless they are part of the admitting diagnosis. “This new focus on hospital-acquired conditions may work to the patient’s benefit,” Dr. Meddings says. “The inclusion of pressure ulcers has led to increased attention to skin exams on admission and preventive measures during hospitalizations. In the past, skin exams upon admission may have been given a lower priority, but that has changed.” Dr. Meddings is concerned that the new rules could force the shifting of resources to areas where the hospital could lose money. If, when, and how many changes will actually take place is still up in the air. “Resource shifting is a concern whenever there is any sort of pay-for-performance attention directed toward one particular complication,” she says. “To balance this, many of the strategies hospitals used to prevent complications are not specific to just the diagnosis that is covered by the HAC.” Dr. Meddings also hopes the new focus on preventable conditions will have a “halo effect” in the healthcare community. For instance, CMS mandating DVT prevention following orthopedic operations will, hopefully, result in a greater awareness of the problem in other susceptible patients. Review the list of conditions that are identified as HACS at the following webpage: CMS List of HACS The Scenario: A patient named Sam entered the Emergency Department (ED) with abdominal pain. He was triaged and escorted to a treatment room. After an assessment, examination, lab tests and imaging, it was determined Sam had appendicitis. He was scheduled for surgery the next morning for an appendectomy. Susan, the utilization review nurse, analyzed Sam’s electronic medical record the next morning. Susan asked herself, “Is the surgery medically necessary?” and “Can it be performed safely in an ambulatory setting or does it require an inpatient admission?” According to the Centers for Medicare & Medicaid Services Glossary (2016), medical necessity is defined as “services or supplies that: are proper and needed for the diagnosis or treatment of a medical condition, are provided for the diagnosis, direct care, and treatment of a medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of the patient or doctor.” An Introduction to Utilization Review Healthcare has changed drastically in the last 100 years. Healthcare costs continue to rise, quality of care is questioned, and chronic diseases are evident now more than ever before. These challenges must be addressed by the industry, and effective solutions are a must. Utilization review (UR) is one solution to the obstacles we face today in the healthcare industry. Utilization review is a method used to match the patient’s clinical picture and care interventions to evidence-based criteria such as MCG care guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate care setting for all levels of services across the arc of patient care. History of Utilization Review Due to rising costs after the induction of health insurance in the 1960s, President Lyndon B. Johnson and the U.S. Congress responded with programs we now call Medicare and Medicaid. Medicare/Medicaid allowed for reimbursement to the physician for a reasonable and customary charge. Due to rising costs, and the offering of healthcare insurance from employers to employees, utilization review was presented. Utilization review, as a process, was introduced in the 1960s to reduce overutilization of resources and identify waste. The utilization review function was initially performed by registered nurses (RNs) in the acute hospital setting. The skillset gained popularity within the health insurance industry, mainly due to growing research about medical necessity, misuse, and overutilization of services. Therefore, health plans began to review claims for medical necessity, and the hospital length of stay (LOS). To contain costs, some health plans required the physician to certify the admission and any subsequent days after the admission. Utilization Review Process There are three activities within the utilization review process: prospective, concurrent and retrospective. Prospective review includes the review of medical necessity for the performance of services or scheduled procedures before admission. Concurrent reviews include a review of medical necessity decisions made while the patient is currently in an acute or post-acute setting. Retrospective reviews involve a review of coverage after treatment is provided. The complete utilization review process consists of precertification, continued stay review, and transition of care. When a patient is admitted to the facility, a first level review is conducted for appropriateness; this includes medical necessity, continued stay, level of care, potential delays in care and progression of care. Medical necessity determines whether the hospital admission is appropriate, justifiable and reimbursable. Continued stay determines if each day of the stay is necessary and if the level of care is appropriate for that day. Level of care determination identifies the most appropriate and needed level of care such as intensive or intermediate versus a medical-surgical floor level of care. System delays are assessed and monitored to identify any potentially avoidable delays in care. Progression of care, utilizing the guideline’s Optimal Recovery Course, moves the patient through the continuum of care without delays and determines if services are appropriate, justifiable and reimbursable. Applying the activities within the utilization review process, the nurse must accurately document the medical necessity and level of care based on evidenced-based criteria (such as MCG). The chart documentation must display the patient’s current condition, and why the condition cannot be safely treated outpatient, and the risk associated if care is not provided at that level of care. In conclusion, although this is an overview of the utilization review technique, it is important to note the process includes other methods such as physician second level review, CMS regulatory requirements, and in some cases clinical documentation improvement. Today, utilization review is one method used to demonstrate the quality of care and protect revenue integrity. Because quality and costs are of paramount importance, utilization review nurses must possess clinical judgment and critical thinking skills to proactively mitigate overutilization and misuse of resources.