GATEWAY HEALTH PLAN^®

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HOSPITAL NEWSFLASH

Inside This Issue:

1.  PRESENT ON ADMISSION DIAGNOSIS AND POA INDICATORS - UPDATE

2. COORDINATION AND CONTINUITY OF CARE

IMPORTANT INFORMATION

Present on Admission Diagnosis and POA Indicators - Update

In MA Bulletin No. 1-07-11(“Preventable Serious Adverse Events”), DPW announced its payment policy for preventable serious events (PSAEs) to acute care general hospitals participating in the MA program.  Case identification of PSAEs is undertaken in part through claims reviews; therefore, DPW also announced in the MA Bulletin the requirement for hospitals to include the applicable Present on Admission (POA) indicator for all diagnosis codes on inpatient claims, regardless of the manner in which claims are submitted (i.e., paper or electronic).

DPW has given similar direction to the HealthChoices managed care organizations (MCOs), by mandating that the MCOs include POA indicators on inpatient encounters that the MCOs are required to submit to DPW.  DPW is requiring the MCOs to implement the POA requirements according to their specifications.  Gateway Health Plan^® is therefore implementing the requirements outlined below with respect to POA indicators on inpatient acute care hospital claims.  POA indicators for all diagnosis codes must be included on inpatient hospital claims to MCOs.  DPW will validate the submission of POA indicators through inpatient managed care encounter submissions, which will then serve as a basis for enforcement by DPW.

Primary and Secondary Diagnosis and POA Indicators

• Effective with claims processed on or after May1, 2009, all new, corrected or resubmitted inpatient claims with dates of discharge on or after July 1, 2008, must have valid POA indicators for each primary and secondary diagnosis code submitted.  Electronic and paper claims submitted with primary and secondary diagnosis codes which do not have corresponding POA indicators will be denied with A D97 “Missing or Invalid Present on Admit Indicator.  Resubmit with a Valid Present on Admit Indicator on all Principal and Secondary Diagnosis Codes.”  

Hospitals are not required to resubmit inpatient claims with discharge dates on or after July 1, 2008, but if these claims are resubmitted, they must include the appropriate POA indicators.  This requirement pertains to any new, corrected or resubmitted claims filed after October 1, 2008, with discharge on or after July 1, 2008. 

Exempt Hospitals

It is important to note that DPW and CMS have different requirements regarding the types of facilities exempt from POA requirements.  While children’s hospitals, cancer hospitals and long-term care hospitals (LTCHs) are exempt from CMS requirement to submit POA indicators, Pennsylvania Medical Assistance requirements differ from CMS requirements in that all children’s hospitals, cancer hospitals and LTCHs participating in the PA Medical Assistance Program must submit POA indicators.  Children’s hospitals, cancer hospitals and LTCHs in Pennsylvania are not exempt from this requirement.  Only psychiatric hospitals, psychiatric units within hospitals, rehabilitation facilities, and rehabilitation units within hospitals are exempt from this reporting requirement.  However, exempt facilities must affirmatively indicate their exempt status on each claim.  Facilities that are exempt from POA reporting must still submit a POA indicator of “1” for each diagnosis code submitted, which will document the facility’s exempt status and prevent claims from being denied.  Blanks will not be accepted. Unlike CMS Medicare rules, the field that holds the applicable POA indicator for the exempt diagnosis code cannot be left blank.

Valid POA Indicators

• Y - Diagnosis was present at the time of inpatient admission
• N – Diagnosis was not present at the time of inpatient admission
• U – Documentation insufficient to determine if condition was present at the time of inpatient admission
• W – Clinically underdetermined.  Provider unable to clinically determine whether the condition was present at the time of admission
• 1 – Exempt from POA reporting.

Note: Regardless of a provider’s exempt status from POA reporting (Children’s Hospitals, Cancer Hospitals, Psych Facilities), OR if the diagnosis code is exempt from POA reporting under CMS guidelines, PA Medicaid procedures require that POA code 1 be added to every diagnosis code on the claim.  The only exception for Gateway will be Skilled Nursing Facilities.

Key Items to Remember

Beginning with claims processed on or before May 1, 2009, all new, corrected or resubmitted inpatient claims with discharge dates on or after July 1, 2008 must contain:

• All primary and secondary diagnoses ( up to 5 digits)
• Corresponding POA indicators for each primary and secondary diagnosis
• If resubmitting  a claim or sending a corrected claim with a discharge date on or after July 1, 2008, it must be corrected to contain applicable POA indicators and diagnosis codes, even if the original claim did not contain this information

Claims will be denied if:

• Primary or secondary diagnosis codes are submitted with a blank POA indicator
• An invalid POA indicator (other than Y, N, U, W, 1) is submitted
• POA indicators are submitted without an associated primary or secondary diagnosis code
• Electronic claims are submitted in an improper format – i.e., if the POA field contains improper spaces, or if the number of POA indicators does not equal the number of diagnosis codes submitted.

Instructions for Reporting Present on Admission (POA) Indicators on UB-04 Claim Form and via Electronic Format

Reporting POA on the UB-04 Claim Form

Field 67 A-Q and 72 A-C

Valid primary and secondary diagnosis codes (up to 5 digits), are to be placed in the unshaded portion of 67 A-Q and 72 A-C, followed by the applicable POA indicator (1 character) in the shaded portion of 67 A-Q and 72 A-C.

Valid POA Indicators

• Y - Diagnosis was present at the time of inpatient admission
• N – Diagnosis was not present at the time of inpatient admission
• U – Documentation insufficient to determine if condition was present at the time of inpatient admission
• W – Clinically underdetermined.  Provider unable to clinically determine whether the condition was present at the time of admission
• 1 – Exempt from POA reporting.

Reporting POA in Electronic Format

The 837I Institutional Electronic Claims process requires the POA be entered in Loop 2300, segment K3, data element K301. K301 = “POA”, followed by a single POA indicator for the primary and all secondary diagnoses reported in the claim.  “POA” must be placed in position 1-3 of the K3 segment and immediately followed by the applicable POA indicators.  The POA indicator for the primary diagnosis code would be the first indicator after “POA”, and when applicable, the POA indicators for each secondary diagnosis code would follow.  The last (primary/secondary) POA indicator must be followed by the letter “Z” or “X” to indicate the end of the data element.

There must be one POA indicator reported for EACH primary and secondary diagnosis code in the claim.  Spaces between the letter “POA” and the POA indicators are not acceptable and will cause your claim to deny.

Coordination and Continuity of Care

Hospital & Skilled Nursing facilities must ensure compliance with the Continuity and Coordination of Care requirements, by ensuring that all discharged summaries and progress reports are reported back to the member’s PCP.

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