When there is a Stage II pressure ulcer documented on admission but no physician documentation on whether it was present on admission, what should the CDI professional do?

When there is a Stage II pressure ulcer documented on admission but no physician documentation on whether it was present on admission, what should the CDI professional do?

• A. Formulate a query to determine if the condition was present on admission
• B. Assume it was not present
• C. Mark as present on admission
• D. Do nothing

Answer: (A)

The essential idea is to verify present-on-admission (POA) status when the chart doesn’t clearly establish whether a condition existed on admission. In this scenario, a Stage II pressure ulcer is documented as present on admission, but there’s no physician documentation confirming POA. The CDI professional should formulate a focused query to obtain the physician’s confirmation of POA. Why this is the best path: confirming POA directly with the physician ensures accurate coding and appropriate impact on quality measures and DRG assignment. If the physician confirms the ulcer was present on admission, it remains POA and typically isn’t treated as a hospital-acquired condition. If the physician indicates it developed after admission or POA remains uncertain, the coding will reflect that, which can change hospital metrics and potential reimbursements. Simply guessing, marking the ulcer as present without confirmation, or taking no action, risks inaccurate coding and misrepresentation of patient care. So, the correct approach is to query for POA clarification. This preserves coding accuracy and aligns with how POA status guides downstream reporting and reimbursement.

The essential idea is to verify present-on-admission (POA) status when the chart doesn’t clearly establish whether a condition existed on admission. In this scenario, a Stage II pressure ulcer is documented as present on admission, but there’s no physician documentation confirming POA. The CDI professional should formulate a focused query to obtain the physician’s confirmation of POA.

Why this is the best path: confirming POA directly with the physician ensures accurate coding and appropriate impact on quality measures and DRG assignment. If the physician confirms the ulcer was present on admission, it remains POA and typically isn’t treated as a hospital-acquired condition. If the physician indicates it developed after admission or POA remains uncertain, the coding will reflect that, which can change hospital metrics and potential reimbursements. Simply guessing, marking the ulcer as present without confirmation, or taking no action, risks inaccurate coding and misrepresentation of patient care.

So, the correct approach is to query for POA clarification. This preserves coding accuracy and aligns with how POA status guides downstream reporting and reimbursement.