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Present on admission: What are hospitals doing about the no-pay policy?
Groups try new approaches to capture POA diagnoses



Published in the October 2008 issue of Today's Hospitalist

BEGINNING THIS MONTH, the Centers for Medicare and Medicaid Services will no longer pay for the treatment costs of certain conditions that the agency deems to be preventable complications—unless physicians document (and billers code) that those conditions were present on admission (POA). Today’s Hospitalist asked several hospitalist programs around the country what they were doing to better capture present-on-admission diagnoses.

Has your hospital hired new staff to help implement POA assessment and documentation?

YES: 8%

“Three dedicated case managers/documentation specialists have been hired specifically to review new admissions and check for adequate documentation.
92% of hospitals are screening for pressure ulcers

For documentation gaps, they will notify the physician directly or leave a bright yellow form in the chart.”

Has your hospital done something in the way of education and training or new admission processes to improve POA screening and documentation?

YES: 92%

Has your hospital changed any of its admission procedures or processes?

YES: 58%

17% of those who are changing their procedures plan to have nurses take photos of any decubiti they note during their initial assessment at admission and place them in the chart.

“We have developed a POA checklist in the ED template that physicians and nurses can mark off.”

“Some of our facilities have developed a checklist of conditions that can be attached to a chart to re-screen for POA conditions.”

“Our ED assessment checklist includes Foley catheter-related UTIs, sacral decubiti and vascular catheter-related bloodstream infections. We are discussing adding the checklist to our attending admission note as well.”

“The coding department is generating multiple reminders and queries at admission and discharge.”

“On admission, the MD checks out whether a pressure ulcer is present or not. Nurses also do a daily assessment and a daily Braden scale assessment.”

“On every ED progress note sheet now available, there is a stamp with three questions:
1. Complete head to toe skin assessment complete? Y N
2. Pressure ulcer present? Y N
3. SWAT or wound care nurse ordered? Y N”

“Our hospital has screening programs in place for MRSA and VRE for patients admitted to specific hospital units, but not for infections or conditions on the POA list at this time.”

Is your hospital implementing routine urinalysis?

YES: 0%

“The ED has reminders to check a urine culture on patients arriving with urinary catheters.”

“If there is a concurring history or examination, a urinalysis is requested.

Have physicians and/or nurses received any training in how to document or assess POA conditions?

“Physicians are receiving ongoing education on appropriate documentation reflecting POA conditions.”

“Company-wide, our physicians completed a POA briefing in the third quarter of 2007 and in the first quarter of 2008. They will also receive additional education related to the POA diagnoses added for the 2009 calendar year.”

“Physicians have had discussions with the quality department documentation.”

“We’ll have our coders circulate throughout the hospital, prompting doctors and nurses to clearly indicate POA when appropriate.”

“Our SWAT (skin/wound assessment team) has developed and implemented extensive education on documenting pressure ulcers for all nurses in the ED and all floor RNs. Education has also been developed and given to ED physicians.”

Has your hospital given specific training to your billing and coding department?

YES: 75%

“Right now in our paper system, the coders identify issues and look to see if there is documentation that explains if the condition is POA. If there is still a question, the coders call the doctors.”

“Facilities are tracking the occurrence of denials secondary to a lack of a POA flag or an actual clinical complication covered by the POA measures.”

Is your hospital currently limiting its POA efforts to only one or two conditions?

YES: 67%

92% of hospitals are screening for pressure ulcers

Is your hospital only screening for pressure ulcers and assessing for UTIs?

YES: 42%

“The original proposed checklist lists all the complications. But at a recent meeting we discussed reducing it because we do not perform cardiac surgery here and perform very well with others.”

“We screen for all of the conditions that fall under the management of a hospitalist, without prejudice.”


PARTICIPANTS: Viviane Alfandary, MD, John Muir Medical Center; Deepak Asudani, MD, Baystate Medical Center; Felix Aguirre, MD, IPC The Hospitalist Company; Kimberly Bell, MD, Centennial Medical Center; Brian Bossard, MD, BryanLGH Medical Center; James Franko, MD, Carilion Roanoke Memorial Hospital; Paul Kettler, MD, Columbia Park Medical Group; John Krisa, MD, HMP of Albany County; Jennifer Meddings, MD, University of Michigan Health System; Mona Patel, DO, Staten Island University Hospital; Eric Rice, MD, Methodist Hospital; Stephen Shaw, MD, Community Hospitalists
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