How Do I Assign the Present on Admission (POA) Indicator? Y, N, U, W and the Exempt List

The present on admission (POA) indicator is reported beside each diagnosis code and each external cause of injury code on an inpatient institutional claim (UB-04 and 837 Institutional). Appendix I of the FY 2027 ICD-10-CM Official Guidelines is the rule set for it. The appendix opens by saying what it is for and what it is not:

Official sourceThese guidelines are to be used as a supplement to the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837 Institutional).

Official sourceThe POA guidelines are not intended to provide guidance on when a condition should be coded, but rather, how to apply the POA indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines.

Two consequences follow. First, the order of work is fixed: the ICD-10-CM codes are assigned first, and the indicator is then assigned to the conditions that were coded. Second, the indicator is not a reason to add or drop a code. Whether a condition is coded at all is decided by Section II (the principal diagnosis) and Section III (additional diagnoses); Appendix I only says what to report beside the codes that survive that test. In the appendix’s words, if a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported.

Who reports it. Appendix I scopes the requirement to all claims involving inpatient admissions to general acute care hospitals, or other facilities that are subject to a law or regulation mandating collection of present on admission information. The appendix does not list which facility types are exempt; that is a matter of the law or regulation that applies to the facility, not of the coding guidelines.

What “present on admission” means. The definition turns on the admission order, not on the moment the patient arrived at the hospital:

Official sourcePresent on admission is defined as present at the time the order for inpatient admission occurs -- conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

The timing cases follow from that sentence. A pressure ulcer first noted in the ED, a fall in the emergency room before the admission order, a complication during outpatient surgery that leads to admission: each was present on admission, because each preceded the order.

Which codes carry one.

Official sourceA POA indicator is assigned to the principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.

Appendix I says nothing about ICD-10-PCS procedure codes; the indicator is a diagnosis-side field. Nor does it say the principal diagnosis is automatically Y: the principal diagnosis is assigned an indicator by the same rules as every other code.

Appendix I lists five options and defines four of them. Verbatim:

Official sourceY = present at the time of inpatient admission N = not present at the time of inpatient admission U = documentation is insufficient to determine if condition was present on admission W = provider is unable to clinically determine whether condition was present on admission or not

The fifth option is written in the appendix as “Unreported/Not used – (Exempt from POA reporting)”. There is no numeric value in the FY 2027 appendix; the exempt option is a blank field. MedCoder’s reading of the five, with the Appendix I rule that produces each:

The difference between U and W is who is uncertain. W records a clinical judgment the provider has made and documented: the status cannot be determined. U records a gap in documentation that nobody has resolved. Appendix I treats the two differently, and the guidance on U is explicit:

Official source“U” should not be routinely assigned and used only in very limited circumstances. Coders are encouraged to query the provider when the documentation is unclear.

The exempt list is not in the guidelines. Appendix I points to the CDC website for the detailed list of ICD-10-CM codes that do not require a POA indicator, and describes what is on it as codes and categories “for circumstances regarding the healthcare encounter or factors influencing health status that do not represent a current disease or injury or that describe conditions that are always present on admission.” The appendix names one range directly, categories Q00-Q99, Congenital anomalies, which are on the exempt list. This guide does not reproduce the list; the published CDC/NCHS file is the authority. On an exempt code:

Official sourceThis is the only circumstance in which the field may be left blank.

1. Finish coding before you start. Select the principal diagnosis under Section II and the additional diagnoses under Section III. Appendix I is applied to the final code set, and it adds nothing to it and removes nothing from it.
2. Check the exempt list first. A code on the CDC/NCHS exempt list gets a blank field, and a blank is correct only there. Every other diagnosis and external cause code gets Y, N, U or W.
3. Take the provider’s explicit statement when there is one. Appendix I assigns Y for any condition the provider explicitly documents as being present on admission, and N for any condition the provider explicitly documents as not present at the time of admission. The guidelines are not a substitute for the provider’s clinical judgment on this question.
4. Otherwise, fix the condition against the admission order. Diagnosed before admission, or chronic: Y. Developed during the ED, observation or outpatient-surgery encounter before the written inpatient order: Y. An acute condition present at admission: Y; one that arose afterward: N. The date of the diagnosis is not the test. Appendix I is direct on timing:

Official sourceThere is no required timeframe as to when a provider (per the definition of “provider” used in these guidelines) must identify or document a condition to be present on admission.

Official sourceDiagnoses subsequently confirmed after admission are considered present on admission if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis, or constitute an underlying cause of a symptom that is present at the time of admission.

5. Open up every combination code. When one code carries more than one clinical concept, each concept has to have been present for Y:

Official sourceAssign “N” if at least one of the clinical concepts included in the code was not present on admission (e.g., COPD with acute exacerbation and the exacerbation was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission).

The same rule covers a chronic condition with an acute exacerbation during the stay: if one code identifies both, apply the multiple-concepts rule; if the code identifies only the chronic condition (Appendix I’s example is an acute exacerbation of chronic leukemia), assign Y. It also covers one code that represents two separate conditions in the same encounter: Y if all were present on admission (bilateral unspecified age-related cataracts), N if any was not (the appendix’s example is T79.2, traumatic secondary and recurrent hemorrhage and seroma, where only one of the two conditions was present on admission). Infection codes that include the causal organism are handled separately:

Official sourceFor infection codes that include the causal organism, assign “Y” if the infection (or signs of the infection) were present on admission, even though the culture results may not be known until after admission (e.g., patient is admitted with pneumonia and the provider documents Pseudomonas as the causal organism a few days later).

6. Uncertain discharge diagnoses follow their symptoms. A final diagnosis qualified as possible, probable, suspected or rule out gets Y when it was based on signs, symptoms or clinical findings suspected at the time of inpatient admission, and N when those findings were not present on admission. An impending or threatened diagnosis is handled the same way.
7. External cause codes answer “when did it happen?” Y for an external cause of morbidity that occurred prior to inpatient admission; N for one that occurred during the inpatient hospitalization.

Official sourceAssign “Y” for any external cause code representing an external cause of morbidity that occurred prior to inpatient admission (e.g., patient fell out of bed at home, patient fell out of bed in emergency room prior to admission)

Official sourceAssign “N” for any external cause code representing an external cause of morbidity that occurred during inpatient hospitalization (e.g., patient fell out of hospital bed during hospital stay, patient experienced an adverse reaction to a medication administered after inpatient admission).

8. Obstetrics and newborns have their own two rules. Whether or not the patient delivers during the current hospitalization does not affect the indicator; the question is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission. Preterm labor on admission: Y. A postpartum hemorrhage during the stay, or fetal distress that develops after admission: N. An obstetrical code that includes more than one diagnosis gets N if any of them was not present on admission; the appendix’s example is category O11, pre-existing hypertension with pre-eclampsia. For the newborn:

Official sourceNewborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered present at admission and should be assigned “Y”.

That includes conditions that occur during delivery; Appendix I lists injury during delivery, meconium aspiration and exposure to streptococcus B in the vaginal canal. Appendix I adds that “Congenital conditions are always considered present on admission”, so a congenital condition coded outside the exempt Q00-Q99 range gets Y.

9. Query before you reach for U. If, at the time of code assignment, the documentation is unclear as to whether a condition was present on admission, Appendix I says it is appropriate to query the provider. It names three triggers:

Official sourceThe provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of findings.

1. Chronic conditions known before admission. Discharge summary lists essential hypertension and type 2 diabetes without complications, both on home medication. I10 and E11.9 are each Y. Appendix I assigns Y for conditions diagnosed prior to admission and gives hypertension, diabetes mellitus and asthma as its examples. The indicator does not depend on when during the stay the provider first wrote them down.
2. A combination code whose second concept arrived late. Admitted for pneumonia with stable COPD; on day 3 the provider documents an acute exacerbation of the COPD. J44.1 carries both the COPD and the exacerbation, and the exacerbation was not present on admission, so J44.1 is N. This is the appendix’s own COPD example. Had the record shown the exacerbation at admission, J44.1 would be Y; the COPD being chronic does not rescue the combination code.
3. Organism identified after admission. Admitted with pneumonia; the culture results on day 3 and the provider documents Pseudomonas. The organism-specific code J15.1 is Y: the infection was present on admission even though the culture result was not. Had the final diagnosis stayed at pneumonia, unspecified organism, J18.9 would be Y on the same facts.
4. A diagnosis suspected at admission and confirmed later. ED note: “possible sepsis, source unclear”; admission order written; on day 2 the provider documents sepsis, organism unspecified. A41.9 is Y, because a diagnosis later confirmed is POA when it was documented as suspected or possible at the time of admission. If severe sepsis is also documented, MedCoder’s reading is that R65.20 takes its own indicator under the acute-conditions rule: Y if the organ dysfunction was present at admission, N if it developed afterward. The sepsis guide covers the code set; this guide covers only the indicator.
5. External cause before admission, and another during the stay. Patient fell out of bed at home and is admitted with a closed fracture of the neck of the right femur. S72.001A is Y, and W06.XXXA (fall from bed, initial encounter) is Y, because the event occurred prior to inpatient admission. Had the only fall been from the hospital bed on day 4, W06.XXXA would be N, because the event occurred during the inpatient hospitalization, and the injury it caused would be N under the acute-conditions rule.
6. Explicitly documented as not present. Progress note, day 5: “stage 2 pressure ulcer, sacral region, not present on admission; developed this admission.” The pressure ulcer code (category L89) is N on the provider’s explicit statement. Had the ED physician documented the same ulcer before the admission order, it would be Y as a condition diagnosed prior to inpatient admission.
7. Obstetrics. Admitted in preterm labor, a code from category O60: Y. The patient delivers; a postpartum hemorrhage during the same stay: N. Delivering during the stay changes nothing about either indicator.
8. Newborn. A newborn with meconium aspiration: Y. Newborns are not considered admitted until after birth, so conditions that occur during delivery are present on admission.
9. Exempt. A congenital anomaly coded to Q00-Q99: the field is left blank, because the category range is on the exempt list. Any other congenital condition is Y.

• Dating the indicator from arrival instead of the admission order. Appendix I defines present on admission by the time the order for inpatient admission occurs. A condition that developed in the ED, in observation or in outpatient surgery before that order is Y, not N.
• Reading a late diagnosis date as N. There is no required timeframe for the provider to identify or document a condition as present on admission; a definitive diagnosis on day 4 does not mean the condition was absent on day 1. When the condition is chronic, or was suspected at admission or underlies a symptom present at admission, those rules assign Y regardless of the diagnosis date.
• Giving a combination code Y because the chronic half was present. The appendix’s own examples are COPD whose exacerbation began after admission, a gastric ulcer that did not bleed until after admission, and asthma in which status asthmaticus developed after admission: all N.
• Using U as the default for thin documentation. U is for very limited circumstances; the expected path is a query. W is different: it is reportable only on the provider’s documented statement that the status cannot be clinically determined; a coder does not infer it from the record.
• Leaving a field blank for any reason other than the exempt list. A missing indicator on a non-exempt code is not the same as an exempt code. The published CDC/NCHS list is the only authority for a blank.
• Letting the indicator decide whether to code. Appendix I is applied after Sections I, II and III have fixed the code set. A condition that does not meet the Section III test for an additional diagnosis is not coded, and so carries no indicator; a condition that does meet it is coded whatever indicator it will get.
• Resolving a documentation conflict yourself. Appendix I is explicit that issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider, and it lists the questions a query should cover: the linking of signs and symptoms, the timing of test results and the timing of findings.
• Treating the principal diagnosis as automatically Y. Appendix I says only that the principal and secondary diagnoses and the external cause codes receive an indicator; it gives the principal diagnosis no special value.

Appendix I ties the determination to the provider and to the record, and it accepts documentation from more than one provider:

Official sourceMedical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission or not.

Official sourceThese guidelines are not a substitute for the provider’s clinical judgment as to the determination of whether a condition was/was not present on admission.

For POA purposes, as elsewhere in the guidelines, “provider” means a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis. So the record needs to show, from a provider:

• When the condition was present relative to the admission order. An ED note, an admitting history or a consultant’s note that places a finding before the order supports Y; a progress note that dates its onset to a hospital day supports N. For an acute condition, a note that only dates the diagnosis, not the condition’s onset, supports neither on its own.
• What was suspected at admission. A differential, a “possible” or a “rule out” written at admission is what later turns a confirmed diagnosis into Y. If the admission note names only a symptom, the question becomes whether the confirmed condition is the underlying cause of that symptom.
• Each concept of a combination code. For a code such as J44.1, the record has to place both the chronic condition and the exacerbation; the exacerbation’s onset decides the indicator.
• The provider’s own answer when it cannot be determined. W is reportable only when the documentation states that the POA status cannot be clinically determined. A query response that says so is that documentation.

Which conditions are coded in the first place is settled before the indicator is reached. Section III defines other diagnoses for reporting purposes as additional clinically significant conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring, and quotes the UHDDS definition:

Official sourceall conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.

Two rules in the main body of the Guidelines bear on the record a POA determination rests on, and neither is a POA rule. Section I.B.14 bases code assignment on the patient’s provider’s documentation, with a short list of exceptions (pressure ulcer stage, BMI and coma scale among them) that may come from other clinicians while the associated diagnosis must still be documented by the provider. That exception is about assigning the code; Appendix I says only that documentation from any provider, as the guidelines define provider, may support the determination. Section I.B.14 and Section I.A.19 both send conflicting documentation back to the provider as a query. Section II.H, repeated in Section III.C, is why an uncertain discharge diagnosis gets an indicator at all: for an inpatient admission, the coder is to

Official sourcecode the condition as if it existed or was established.

Section III.C carries the scope note for that rule:

Official sourceNote: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Once such a diagnosis is coded, Appendix I assigns its indicator from the timing of the signs, symptoms or findings it was based on.

MedCoder treats the indicator as an inpatient institutional fact. On an inpatient institutional claim each diagnosis needs a present-on-admission indicator unless the code is on the POA exempt list; professional claims do not carry one. Claim Check splits a submitted code list into the codes that require an indicator and the codes on the exempt list, and it does not require POA indicators for every claim type. Where the check is shown only because the list carries ICD-10-CM diagnoses, it says so and marks the result as contextual rather than a claim error.

On an inpatient claim the indicators are inputs, not output. Given the principal diagnosis, the secondary diagnoses with their present-on-admission indicators, the procedures, the sex, the discharge status and whether the hospital reports present-on-admission indicators, MedCoder’s own implementation of CMS’s published MS-DRG grouper logic groups the claim against CMS’s published grouper tables for the fiscal year covering the date of service, and shows which codes moved the result. MedCoder proposes the first code entered as the principal diagnosis, where that code is a diagnosis on the claim, for the coder to confirm or change; every present-on-admission indicator starts unreported, and none is assumed. The hospital-acquired-condition step of that grouping reads the indicators. If that step meets a condition and finds a code carrying a hospital-acquired condition whose present-on-admission status is unreported, exempt or invalid, it can return the claim ungrouped and states CMS’s return code in words; the MS-DRG grouper guide explains when that happens. Of the codes in the examples above, J18.9 and R65.20 are each a major complication or comorbidity as a secondary diagnosis in the v44 grouper (Definitions of MS-DRGs, Appendix C), so a claim carrying either is one where the inpatient details, the indicators among them, change what the grouper can show. MedCoder is not certified, approved, endorsed, or operated by CMS, and nothing in Claim Check is a coverage or payment determination.