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October 30, 2022

Documentation is insufficient to determine if the condition is present onadmission

Following a 3-day inpatient stay, a patient was discharged with the following dischargediagnoses: · Principal Diagnosis: Exacerbation of Multiple Sclerosis. · Secondary Diagnoses: · Diabetes Mellitus, Type 2 (chronic) · Diabetic ulcer, debrided on day 2 The provider was queried to determine the Present on Admission (POA) Indicator for thediabetic ulcer. POA Reporting Definitions (from ICD Appendix I) · Y = present at the time of inpatient admission · N = not present at the time of inpatient admission

HIM2945_Module 02· U = documentation is insufficient to determine if the condition is present onadmission · W = provider is unable to clinically determine whether the condition was present onadmission or not Query: 1. Please indicate if the diabetic ulcer was present at the time of admission

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