POA Logic Indicator (Exempt Flag)

With the introduction of the Present On Admission concept came three distinct data elements:

• POA Logic Indicator / Exempt flag: an official grouper parameter which is a record-level flag which tells the grouper whether  or not POA logic (including the Hospital Acquired Condition rules, or HAC);
• POA Flag: an official grouper parameter which is a diagnosis-level flag which tells the group how to process this code against the HAC rules
• Have POA Flag: a DRGGroupers software parameters which, when part of our API, tells our software whether or not to look for POA flags

(Since POA comes up in so many contexts, we prefer to call the "POA Logic Indicator" something else: "the exempt-from-HAC flag" or simply "the exempt flag." Be advised that this is not how CMS refers to this data element.)

There are only two legal values for this flag:


X - Exempt from POA reporting
Z - Requires POA reporting

Note that "2" seems to be used by the grouper folks to means "throw me an error if there is HAC rule processing to do."

Present On Admission (POA) Flags

Starting with version 33 and ICD10 support, diagnosis codes are supposed to have Present On Admission (POA) flags.

(Unless the institution or patient encounter is "exempt" which would be indicated by the POA Logic Indicator which we call "the exempt flag." The POA Logic Indicator gets its own post to keep confusion to a minimum.)

Here are the CMS definitions of the legal values for this single character flag:

Flag	Meaning
Y	Yes, present at the time of inpatient admission
N	No, not present at the time of inpatient admission
U	Insufficient documentation to determine if present on admission
W	Clinically unable to determine if present at time of admission
1	Code is exempt from POA reporting (Used on 4010 form)
Blank	Code is exempt from POA reporting (Used on 5010 form, effective 01/01/2011)

Many of our APIs have a "Have POA" flag which is something different: the "Have POA" flag is a record-level indication of whether or not there are POA flags in the submitted diagnosis data. The "Have POA" flag is either "y" for yes or "n" for no.

The POA flags are single-character fields at the individual diagnosis code level. There are up to 25 diagnosis codes accepted for DRG assignment and if you are using POA flags, every code should have one.

In their test data set,CMS passes the POA flag to its grouper as the last character of a fixed-width field. We support that methodology in our DRGFilt product's fixed-with mode and in our C-callable DLL as these are environments in which appending an indicator is relatively easy.

We also support passing in separate POA flag fields in our DRGFilt product's CSV mode and in our VB-callable DLL as there environments generally have better support for separate fields than for character manipulation.

DLL Return Code of 9

QUESTION

What does a return code of 9 from the VB-Callable DLL mean?

ANSWER

This return code comes from the DRG Assignment Engine (DAE) and is common across all of our products.

This return code means "input record has Present-on-Admission (POA) violations and the institution is not exempt from HAC processing."

For more about HAC and POA support, please visit this blog entry: How To Use POA

UPDATE: if you append an 'e' to the version number, the DAE assumes that the hospital(s) are exempt and HAC checking is not done at all.

How to Use POA

QUESTION

As yoyu know, DRG versions 25 and up require the use of the Present On Admission (POA) indicator associated with ICD9 diagnosis codes for the grouping of DRGs. Your grouper software does support versions 25 and 26, but no where in your documentation do I find any reference to POAs and how they should be fed into the data file, or defined in the control file.

We need this information asap in order to ensure that the grouper is working correctly. Please email or call me at your earliest convenience.

ANSWER

Please find attached our most recent documentation, which has a healthy entry in the Index under POA.

I am not sure which of our products you are using, but POA should be supported across the product line. To quote the docs on POA support in general:

Note: as of version 26, released in 2008, the DRG version can have either
a 'p' or an 'e' or both appeneded to it. If there is a trailing 'p', it
is assumed that the last character of every diagnosis code is a POA flag.
If the there is a trailing 'e', then the source institution is presumed
to be exempt from the HAC. Thus "26p" specifies POA support, while "26"
does not. "25p" does not make sense.

To quote the glossary on POA:

In order to avoid paying for medical mistakes, diagnoses are now
flagged as having been present on admission (POA).

The values for the POA flag are not, as one might expect, simply
Y or N; rather the following options are defined:

-Y for Yes
-N for No
-U for Unspecified
-W for clinically undetermined
-1 for unreported / not used / exempt from reporting

To quote from Chapter 5, on our DRGFilt product:
The keyword "poa " specifies where, in the diagnosis code, to find the
POA flag. If the diagnosis code length (specified by dlx) is 8, it is
typical to find the POA flag at offset 7, that is to say the last character
of every code.

The keyword "exmp" specifies that the institution from which these data
come is exempt from the HAC.

Note that if neither of these keywords is present, the software assumes that
POA is irrelevant and that the source institution is to be treated as exempt
from the HAC.