Q&A: Querying for COVID-19 POA

Q: A patient was admitted to our facility with COVID-19-like symptoms, tested negative for COVID-19. Several days later, however, the patient was retested and found to be positive for COVID-19. Should we query the physician or assign a present on admission (POA) indicator of "no" or "unknown"?

A: Due to the clinical difficulties of COVID-19 testing (e.g., false negative results), a POA query to the physician is warranted in this case. In addition, coders should be mindful of the POA reporting guidelines found in appendix I of the 2021 ICD-10-CM Official Guidelines for Coding and Reporting. These guidelines state, “There is no required timeframe as to when a provider ... must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis ... for a period of time after admission.”

For more information, see "Paying close attention to COVID-19 POA indicators" in the March 2021 issue of HIM Briefings.