The Hospital-Acquired Condition Reduction Program designates diagnosis and procedures that are considered preventable in the inpatient setting. One of the conditions applicable for FY 2015 is pressure ulcers (ICD-9-CM code 707.0X/ ICD-10-CM codes L89.XXX, stages 3&4). To identify whether the pressure ulcer was present when the patient was admitted or was acquired during the hospital stay, the hospital must report a present on admission code for most diagnoses on the claim form. Scenario: Stephanie is the coding manager at Anywhere Hospital. The coders have been charged with applying the present on admission indicator code. Stephanie has collected data over the past six months. It is quite clear from the data that there is an issue with either the documentation of pressure ulcers, assignment of the POA indicator, or the quality of care provided at Anywhere Hospital. Stephanie has requested that Sally, one of the quality managers, assist her with this issue. 6 POA Report for Pressure Ulcers (707.0x) October–March POA Code Description Volume Y Yes, present on admission 15 N No, not present on admission 30 U Unknown, insufficient documentation 45 W Clinically undetermined 3 1 Exempt from POA reporting 0 It is clear that a medical record audit is necessary to determine if there is a documentation, POA assignment or quality of care issue. Design an audit plan for this issue. What questions should be asked? What processes need to be examined? Who should conduct the audit?
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