ICD-10 Guidelines
Appendix I
Present on Admission Reporting Guidelines
Introduction
These guidelines are to be used as a supplement to the ICD-10-CM Official Guidelines for
Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator
for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837
Institutional).
These guidelines are not intended to replace any guidelines in the main body of the ICD-10-CM
Official Guidelines for Coding and Reporting. The POA guidelines are not intended to provide
guidance on when a condition should be coded, but rather, how to apply the POA indicator to the
final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of
the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA
indicator should then be assigned to those conditions that have been coded.
As stated in the Introduction to the ICD-10-CM Official Guidelines for Coding and Reporting, a
joint effort between the healthcare provider and the coder is essential to achieve complete and
accurate documentation, code assignment, and reporting of diagnoses and procedures. The
importance of consistent, complete documentation in the medical record cannot be
overemphasized. Medical record documentation from any provider involved in the care and
treatment of the patient may be used to support the determination of whether a condition was
present on admission or not. In the context of the official coding guidelines, the term “provider”
means a physician or any qualified healthcare practitioner who is legally accountable for
establishing the patient’s diagnosis.
These guidelines are not a substitute for the provider’s clinical judgment as to the determination
of whether a condition was/was not present on admission. The provider should be queried
regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of
findings.
Please see the CDC website for the detailed list of ICD-10-CM codes that do not require the use
of a POA indicator (https://www.cdc.gov/nchs/icd/icd10cm.htm). The codes and categories on
this exempt list are for circumstances regarding the healthcare encounter or factors influencing
health status that do not represent a current disease or injury or that describe conditions that are
always present on admission.
General Reporting Requirements
All claims involving inpatient admissions to general acute care hospitals or other
facilities that are subject to a law or regulation mandating collection of present on
admission information.
Present on admission is defined as 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 as present on admission.
POA indicator is assigned to principal and secondary diagnoses (as defined in Section II
of the Official Guidelines for Coding and Reporting) and the external cause of injury
codes.
Issues related to inconsistent, missing, conflicting or unclear documentation must still be
resolved by the provider.
If a condition would not be coded and reported based on UHDDS definitions and current
official coding guidelines, then the POA indicator would not be reported.
Reporting Options
Y – Yes
N - No
U - Unknown
W – Clinically undetermined
Unreported/Not used – (Exempt from POA reporting)
Reporting Definitions
Y = present at the time of inpatient admission
N = not present at the time of inpatient admission
U = documentation is insufficient to determine if condition is present on admission
W = provider is unable to clinically determine whether condition was present on
admission or not
Timeframe for POA Identification and Documentation
There is no required timeframe as to when a provider (per the definition of “provider”
used in these guidelines) must identify or document a condition to be present on
admission. In some clinical situations, it may not be possible for a provider to make a
definitive diagnosis (or a condition may not be recognized or reported by the patient) for
a period of time after admission. In some cases, it may be several days before the
provider arrives at a definitive diagnosis. This does not mean that the condition was not
present on admission. Determination of whether the condition was present on admission
or not will be based on the applicable POA guideline as identified in this document, or on
the provider’s best clinical judgment.
If at the time of code assignment the documentation is unclear as to whether a condition
was present on admission or not, it is appropriate to query the provider for clarification.
Assigning the POA Indicator
Condition is on the “Exempt from Reporting” list
Leave the “present on admission” field blank if the condition is on the list of ICD10-CM codes for which this field is not applicable. This is the only circumstance
in which the field may be left blank.
POA Explicitly Documented
Assign Y for any condition the provider explicitly documents as being present on
admission.
Assign N for any condition the provider explicitly documents as not present at the
time of admission.
Conditions diagnosed prior to inpatient admission
Assign “Y” for conditions that were diagnosed prior to admission (example:
hypertension, diabetes mellitus, asthma)
Conditions diagnosed during the admission but clearly present before admission
Assign “Y” for conditions diagnosed during the admission that were clearly
present but not diagnosed until after admission occurred.
Diagnoses subsequently confirmed after admission are considered present on
admission if at the time of admission they are documented as suspected, possible,
rule out, differential diagnosis, or constitute an underlying cause of a symptom
that is present at the time of admission.
Condition develops during outpatient encounter prior to inpatient admission
Assign Y for any condition that develops during an outpatient encounter prior to a
written order for inpatient admission.
Documentation does not indicate whether condition was present on admission
Assign “U” when the medical record documentation is unclear as to whether the
condition was present on admission. “U” should not be routinely assigned and
used only in very limited circumstances. Coders are encouraged to query the
providers when the documentation is unclear.
Documentation states that it cannot be determined whether the condition was or was not
present on admission
Assign “W” when the medical record documentation indicates that it cannot be
clinically determined whether or not the condition was present on admission.
Chronic condition with acute exacerbation during the admission
If a single code identifies both the chronic condition and the acute exacerbation,
see POA guidelines pertaining to codes that contain multiple clinical concepts.
If a single code only identifies the chronic condition and not the acute
exacerbation (e.g., acute exacerbation of chronic leukemia), assign “Y.”
Conditions documented as possible, probable, suspected, or rule out at the time of
discharge
If the final diagnosis contains a possible, probable, suspected, or rule out
diagnosis, and this diagnosis was based on signs, symptoms or clinical findings
suspected at the time of inpatient admission, assign “Y.”
If the final diagnosis contains a possible, probable, suspected, or rule out
diagnosis, and this diagnosis was based on signs, symptoms or clinical findings
that were not present on admission, assign “N”.
Conditions documented as impending or threatened at the time of discharge
If the final diagnosis contains an impending or threatened diagnosis, and this
diagnosis is based on symptoms or clinical findings that were present on
admission, assign “Y”.
If the final diagnosis contains an impending or threatened diagnosis, and this
diagnosis is based on symptoms or clinical findings that were not present on
admission, assign “N”.
Acute and Chronic Conditions
Assign “Y” for acute conditions that are present at time of admission and N for
acute conditions that are not present at time of admission.
Assign “Y” for chronic conditions, even though the condition may not be
diagnosed until after admission.
If a single code identifies both an acute and chronic condition, see the POA
guidelines for codes that contain multiple clinical concepts.
Codes That Contain Multiple Clinical Concepts
Assign “N” if at least one of the clinical concepts included in the code was not
present on admission (e.g., COPD with acute exacerbation and the exacerbation
was not present on admission; gastric ulcer that does not start bleeding until after
admission; asthma patient develops status asthmaticus after admission).
Assign “Y” if all of the clinical concepts included in the code were present on
admission (e.g., duodenal ulcer that perforates prior to admission).
For infection codes that include the causal organism, assign “Y” if the infection
(or signs of the infection) were present on admission, even though the culture
results may not be known until after admission (e.g., patient is admitted with
pneumonia and the provider documents Pseudomonas as the causal organism a
few days later).
Same Diagnosis Code for Two or More Conditions
When the same ICD-10-CM diagnosis code applies to two or more conditions
during the same encounter (e.g. two separate conditions classified to the same
ICD-10-CM diagnosis code):
Assign “Y” if all conditions represented by the single ICD-10-CM code were
present on admission (e.g. bilateral unspecified age-related cataracts).
Assign “N” if any of the conditions represented by the single ICD-10-CM code
was not present on admission (e.g. traumatic secondary and recurrent hemorrhage
and seroma is assigned to a single code T79.2, but only one of the conditions was
present on admission).
Obstetrical conditions
Whether or not the patient delivers during the current hospitalization does not
affect assignment of the POA indicator. The determining factor for POA
assignment is whether the pregnancy complication or obstetrical condition
described by the code was present at the time of admission or not.
If the pregnancy complication or obstetrical condition was present on admission
(e.g., patient admitted in preterm labor), assign “Y”.
If the pregnancy complication or obstetrical condition was not present on
admission (e.g., 2nd degree laceration during delivery, postpartum hemorrhage
that occurred during current hospitalization, fetal distress develops after
admission), assign “N”.
If the obstetrical code includes more than one diagnosis and any of the diagnoses
identified by the code were not present on admission assign “N”.
(e.g., Category O11, Pre-existing hypertension with pre-eclampsia)
Perinatal conditions
Newborns are not considered to be admitted until after birth. Therefore, any
condition present at birth or that developed in utero is considered present at
admission and should be assigned “Y”. This includes conditions that occur during
delivery (e.g., injury during delivery, meconium aspiration, exposure to
streptococcus B in the vaginal canal).
Congenital conditions and anomalies
Assign “Y” for congenital conditions and anomalies except for categories Q00-
Q99, Congenital anomalies, which are on the exempt list. Congenital conditions
are always considered present on admission.
External cause of injury codes
Assign “Y” for any external cause code representing an external cause of
morbidity that occurred prior to inpatient admission (e.g., patient fell out of bed at
home, patient fell out of bed in emergency room prior to admission)
Assign “N” for any external cause code representing an external cause of
morbidity that occurred during inpatient hospitalization (e.g., patient fell out of
hospital bed during hospital stay, patient experienced an adverse reaction to a
medication administered after inpatient admission).
Appendix I
Present on Admission Reporting Guidelines
Introduction
These guidelines are to be used as a supplement to the ICD-10-CM Official Guidelines for
Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator
for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837
Institutional).
These guidelines are not intended to replace any guidelines in the main body of the ICD-10-CM
Official Guidelines for Coding and Reporting. The POA guidelines are not intended to provide
guidance on when a condition should be coded, but rather, how to apply the POA indicator to the
final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of
the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA
indicator should then be assigned to those conditions that have been coded.
As stated in the Introduction to the ICD-10-CM Official Guidelines for Coding and Reporting, a
joint effort between the healthcare provider and the coder is essential to achieve complete and
accurate documentation, code assignment, and reporting of diagnoses and procedures. The
importance of consistent, complete documentation in the medical record cannot be
overemphasized. Medical record documentation from any provider involved in the care and
treatment of the patient may be used to support the determination of whether a condition was
present on admission or not. In the context of the official coding guidelines, the term “provider”
means a physician or any qualified healthcare practitioner who is legally accountable for
establishing the patient’s diagnosis.
These guidelines are not a substitute for the provider’s clinical judgment as to the determination
of whether a condition was/was not present on admission. The provider should be queried
regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of
findings.
Please see the CDC website for the detailed list of ICD-10-CM codes that do not require the use
of a POA indicator (https://www.cdc.gov/nchs/icd/icd10cm.htm). The codes and categories on
this exempt list are for circumstances regarding the healthcare encounter or factors influencing
health status that do not represent a current disease or injury or that describe conditions that are
always present on admission.
General Reporting Requirements
All claims involving inpatient admissions to general acute care hospitals or other
facilities that are subject to a law or regulation mandating collection of present on
admission information.
Present on admission is defined as 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 as present on admission.
POA indicator is assigned to principal and secondary diagnoses (as defined in Section II
of the Official Guidelines for Coding and Reporting) and the external cause of injury
codes.
Issues related to inconsistent, missing, conflicting or unclear documentation must still be
resolved by the provider.
If a condition would not be coded and reported based on UHDDS definitions and current
official coding guidelines, then the POA indicator would not be reported.
Reporting Options
Y – Yes
N - No
U - Unknown
W – Clinically undetermined
Unreported/Not used – (Exempt from POA reporting)
Reporting Definitions
Y = present at the time of inpatient admission
N = not present at the time of inpatient admission
U = documentation is insufficient to determine if condition is present on admission
W = provider is unable to clinically determine whether condition was present on
admission or not
Timeframe for POA Identification and Documentation
There is no required timeframe as to when a provider (per the definition of “provider”
used in these guidelines) must identify or document a condition to be present on
admission. In some clinical situations, it may not be possible for a provider to make a
definitive diagnosis (or a condition may not be recognized or reported by the patient) for
a period of time after admission. In some cases, it may be several days before the
provider arrives at a definitive diagnosis. This does not mean that the condition was not
present on admission. Determination of whether the condition was present on admission
or not will be based on the applicable POA guideline as identified in this document, or on
the provider’s best clinical judgment.
If at the time of code assignment the documentation is unclear as to whether a condition
was present on admission or not, it is appropriate to query the provider for clarification.
Assigning the POA Indicator
Condition is on the “Exempt from Reporting” list
Leave the “present on admission” field blank if the condition is on the list of ICD10-CM codes for which this field is not applicable. This is the only circumstance
in which the field may be left blank.
POA Explicitly Documented
Assign Y for any condition the provider explicitly documents as being present on
admission.
Assign N for any condition the provider explicitly documents as not present at the
time of admission.
Conditions diagnosed prior to inpatient admission
Assign “Y” for conditions that were diagnosed prior to admission (example:
hypertension, diabetes mellitus, asthma)
Conditions diagnosed during the admission but clearly present before admission
Assign “Y” for conditions diagnosed during the admission that were clearly
present but not diagnosed until after admission occurred.
Diagnoses subsequently confirmed after admission are considered present on
admission if at the time of admission they are documented as suspected, possible,
rule out, differential diagnosis, or constitute an underlying cause of a symptom
that is present at the time of admission.
Condition develops during outpatient encounter prior to inpatient admission
Assign Y for any condition that develops during an outpatient encounter prior to a
written order for inpatient admission.
Documentation does not indicate whether condition was present on admission
Assign “U” when the medical record documentation is unclear as to whether the
condition was present on admission. “U” should not be routinely assigned and
used only in very limited circumstances. Coders are encouraged to query the
providers when the documentation is unclear.
Documentation states that it cannot be determined whether the condition was or was not
present on admission
Assign “W” when the medical record documentation indicates that it cannot be
clinically determined whether or not the condition was present on admission.
Chronic condition with acute exacerbation during the admission
If a single code identifies both the chronic condition and the acute exacerbation,
see POA guidelines pertaining to codes that contain multiple clinical concepts.
If a single code only identifies the chronic condition and not the acute
exacerbation (e.g., acute exacerbation of chronic leukemia), assign “Y.”
Conditions documented as possible, probable, suspected, or rule out at the time of
discharge
If the final diagnosis contains a possible, probable, suspected, or rule out
diagnosis, and this diagnosis was based on signs, symptoms or clinical findings
suspected at the time of inpatient admission, assign “Y.”
If the final diagnosis contains a possible, probable, suspected, or rule out
diagnosis, and this diagnosis was based on signs, symptoms or clinical findings
that were not present on admission, assign “N”.
Conditions documented as impending or threatened at the time of discharge
If the final diagnosis contains an impending or threatened diagnosis, and this
diagnosis is based on symptoms or clinical findings that were present on
admission, assign “Y”.
If the final diagnosis contains an impending or threatened diagnosis, and this
diagnosis is based on symptoms or clinical findings that were not present on
admission, assign “N”.
Acute and Chronic Conditions
Assign “Y” for acute conditions that are present at time of admission and N for
acute conditions that are not present at time of admission.
Assign “Y” for chronic conditions, even though the condition may not be
diagnosed until after admission.
If a single code identifies both an acute and chronic condition, see the POA
guidelines for codes that contain multiple clinical concepts.
Codes That Contain Multiple Clinical Concepts
Assign “N” if at least one of the clinical concepts included in the code was not
present on admission (e.g., COPD with acute exacerbation and the exacerbation
was not present on admission; gastric ulcer that does not start bleeding until after
admission; asthma patient develops status asthmaticus after admission).
Assign “Y” if all of the clinical concepts included in the code were present on
admission (e.g., duodenal ulcer that perforates prior to admission).
For infection codes that include the causal organism, assign “Y” if the infection
(or signs of the infection) were present on admission, even though the culture
results may not be known until after admission (e.g., patient is admitted with
pneumonia and the provider documents Pseudomonas as the causal organism a
few days later).
Same Diagnosis Code for Two or More Conditions
When the same ICD-10-CM diagnosis code applies to two or more conditions
during the same encounter (e.g. two separate conditions classified to the same
ICD-10-CM diagnosis code):
Assign “Y” if all conditions represented by the single ICD-10-CM code were
present on admission (e.g. bilateral unspecified age-related cataracts).
Assign “N” if any of the conditions represented by the single ICD-10-CM code
was not present on admission (e.g. traumatic secondary and recurrent hemorrhage
and seroma is assigned to a single code T79.2, but only one of the conditions was
present on admission).
Obstetrical conditions
Whether or not the patient delivers during the current hospitalization does not
affect assignment of the POA indicator. The determining factor for POA
assignment is whether the pregnancy complication or obstetrical condition
described by the code was present at the time of admission or not.
If the pregnancy complication or obstetrical condition was present on admission
(e.g., patient admitted in preterm labor), assign “Y”.
If the pregnancy complication or obstetrical condition was not present on
admission (e.g., 2nd degree laceration during delivery, postpartum hemorrhage
that occurred during current hospitalization, fetal distress develops after
admission), assign “N”.
If the obstetrical code includes more than one diagnosis and any of the diagnoses
identified by the code were not present on admission assign “N”.
(e.g., Category O11, Pre-existing hypertension with pre-eclampsia)
Perinatal conditions
Newborns are not considered to be admitted until after birth. Therefore, any
condition present at birth or that developed in utero is considered present at
admission and should be assigned “Y”. This includes conditions that occur during
delivery (e.g., injury during delivery, meconium aspiration, exposure to
streptococcus B in the vaginal canal).
Congenital conditions and anomalies
Assign “Y” for congenital conditions and anomalies except for categories Q00-
Q99, Congenital anomalies, which are on the exempt list. Congenital conditions
are always considered present on admission.
External cause of injury codes
Assign “Y” for any external cause code representing an external cause of
morbidity that occurred prior to inpatient admission (e.g., patient fell out of bed at
home, patient fell out of bed in emergency room prior to admission)
Assign “N” for any external cause code representing an external cause of
morbidity that occurred during inpatient hospitalization (e.g., patient fell out of
hospital bed during hospital stay, patient experienced an adverse reaction to a
medication administered after inpatient admission).