New “Present on Admission” Indicator Requirement for Hospital Claims

Inpatient acute care hospitals that are paid under the TRICARE diagnosis-related group (DRG) payment system will be required to report a “present on admission” (POA) indicator for every diagnosis on inpatient acute care hospital claims. This policy change is effective for admissions on or after Oct. 1, 2009.

Providers will report POA indicators to TRICARE the same way they are reported to the Centers for Medicare & Medicaid Services, and in accordance with the UB-04 Data Specifications Manual and ICD-9-CM Official Guidelines for Coding and Reporting. The five POA indicator reporting options are:

• Y = The condition was present on admission.
• W = The provider has determined, based on data and clinical judgment, that it is not possible to document when the onset of the condition occurred.
• N = The condition was not present on admission.
• U = Documentation is insufficient to determine if the condition was present at the time of admission.
• 1 = The hospital is exempt from POA reporting

POA is defined as “present at the time the order for inpatient admission occurs.” Including POA indicators on claims will allow conditions that were acquired while a patient was in the hospital – and that could have been reasonably prevented – to be tracked. As a result of this policy change, TRICARE will no longer reimburse for services related to hospital-acquired conditions.

The following types of facilities are exempt from the TRICARE POA indicator requirement:

• Critical access hospitals
• Long-term care hospitals
• Maryland waiver hospitals
• Cancer hospitals
• Children’s inpatient hospitals
• Indian Health Services hospitals and/or facilities
• Inpatient rehabilitation hospitals
• Psychiatric hospitals
• Sole community hospitals
• Veterans Administration hospitals

Effective Oct. 1, 2009, TRICARE will deny any claim from a non-exempt facility that does not report a valid POA indicator for each diagnosis on the claim. The DRG payment is considered payment in full, and the hospital cannot bill a beneficiary for any charges related to a hospital-acquired condition. TRICARE grouper software will be modified to ensure that hospital-acquired condition logic is not applied to claims from exempt hospitals.

Hospital-acquired conditions and their respective diagnosis codes will be posted at www.tricare.mil/drgrates in September.

For more information on the POA indicator requirement, refer to the TRICARE Reimbursement Manual (Chapter 6, Section 8) at www.tricare.mil.

Published Date: 07/23/2009