Present on admission — Appendix I
Four indicators, one blank field, and the rules that decide which conditions a hospital is recorded as having caused.
Present on admission means present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter — including in the emergency department, in observation, or during outpatient surgery — are considered present on admission.
These guidelines supplement the main coding guidelines. They do not replace them and they do not provide guidance on when a condition should be coded — only on how to apply the POA indicator to the final set of diagnosis codes already assigned in accordance with Sections I, II and III. The POA indicator is assigned after code assignment.
General reporting requirements#
| Requirement | Detail |
|---|---|
| Which claims | All claims involving inpatient admissions to general acute care hospitals or other facilities subject to a law or regulation mandating collection of present on admission information |
| Definition | Present at the time the order for inpatient admission occurs. Conditions developing during an outpatient encounter — emergency department, observation, or outpatient surgery — are considered present on admission |
| Which codes | A POA indicator is assigned to the principal and secondary diagnoses as defined in Section II, and to the external cause of injury codes |
| Documentation problems | Issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider |
| Codes that are not reported | 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 |
| Whose documentation | Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination |
| Timeframe | There is no required timeframe for a provider to identify or document a condition as present on admission. It may take several days to reach a definitive diagnosis — that does not mean the condition was not present on admission |
| When unclear | QUERY If at the time of code assignment the documentation is unclear as to whether a condition was present on admission, it is appropriate to query the provider |
| The exempt list | Published by the CDC — see the NCHS ICD-10-CM files page. The exempt codes are for circumstances regarding the encounter, or factors influencing health status, that do not represent a current disease or injury, or that describe conditions always present on admission |
The reporting options#
| Indicator | Definition |
|---|---|
| Y | Present at the time of inpatient admission |
| N | Not present at the time of inpatient admission |
| U | Documentation is insufficient to determine if the condition was present on admission |
| W | Provider is unable to clinically determine whether the condition was present on admission or not |
| Unreported / not used | Exempt from POA reporting — the field is left blank. ALWAYS This is the only circumstance in which the field may be left blank |
Assigning the indicator — every rule#
| Circumstance | Indicator |
|---|---|
| Condition is on the exempt from reporting list | Blank |
| Provider explicitly documents the condition as present on admission | Y |
| Provider explicitly documents the condition as not present at the time of admission | N |
| Conditions diagnosed prior to inpatient admission — for example hypertension, diabetes mellitus, asthma | Y |
| Conditions diagnosed during the admission but clearly present before it | Y |
| Diagnoses subsequently confirmed after admission that, at the time of admission, were documented as suspected, possible, rule out, differential diagnosis, or constituted an underlying cause of a symptom present at the time of admission | Y |
| Condition develops during an outpatient encounter prior to a written order for inpatient admission | Y |
| Documentation does not indicate whether the condition was present on admission | U — not routinely assigned; QUERY query the provider |
| Documentation states it cannot be clinically determined whether the condition was present | W |
| Chronic condition with an acute exacerbation during the admission, where a single code identifies both the chronic condition and the exacerbation | See the multiple clinical concepts rule below |
| Chronic condition with acute exacerbation, where the single code identifies only the chronic condition and not the exacerbation — for example acute exacerbation of chronic leukemia | Y |
| Possible, probable, suspected or rule out diagnosis at discharge, based on signs, symptoms or clinical findings suspected at the time of admission | Y |
| The same, but based on findings that were not present on admission | N |
| Impending or threatened diagnosis at discharge, based on symptoms or findings present on admission | Y |
| The same, based on symptoms or findings not present on admission | N |
| Acute conditions present at the time of admission | Y |
| Acute conditions not present at the time of admission | N |
| Chronic conditions | Y — even though the condition may not be diagnosed until after admission |
| A single code identifying both an acute and a chronic condition | See the multiple clinical concepts rule |
Codes that contain multiple clinical concepts#
| Rule | Indicator | Guideline example |
|---|---|---|
| At least one of the clinical concepts included in the code was not present on admission | N | COPD with acute exacerbation where the exacerbation was not present on admission; a gastric ulcer that does not start bleeding until after admission; an asthma patient who develops status asthmaticus after admission |
| All of the clinical concepts included in the code were present on admission | Y | A duodenal ulcer that perforates prior to admission |
| Infection codes that include the causal organism, where the infection or signs of it were present on admission | Y | A patient admitted with pneumonia where the provider documents Pseudomonas as the causal organism a few days later — the culture result may not be known until after admission |
| Same code, two or more conditions | Indicator |
|---|---|
| All conditions represented by the single code were present on admission — for example bilateral unspecified age-related cataracts | Y |
Any of the conditions represented by the single code was not present on admission — for example traumatic secondary and recurrent haemorrhage and seroma, both assigned to T79.2, where only one was present on admission | N |
Obstetric, perinatal, congenital and external cause codes#
| Category | Rule |
|---|---|
| Obstetric conditions | Whether or not the patient delivers during the current hospitalisation does not affect the POA indicator. The determining factor is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission. Present on admission, such as a patient admitted in preterm labour → Y. Not present, such as a second degree laceration during delivery, a postpartum haemorrhage occurring during the hospitalisation, or fetal distress developing after admission → N. Where the obstetric code includes more than one diagnosis and any of them was not present on admission → N (for example category O11, pre-existing hypertension with pre-eclampsia) |
| Perinatal conditions | Newborns are not considered admitted until after birth. Therefore any condition present at birth or that developed in utero is considered present at admission and is assigned Y — including conditions occurring during delivery, such as injury during delivery, meconium aspiration, and exposure to streptococcus B in the vaginal canal |
| Congenital conditions and anomalies | Assign Y — congenital conditions are always considered present on admission — except for categories Q00–Q99, which are on the exempt list |
| External cause of injury codes | Assign Y for any external cause code representing a cause of morbidity that occurred prior to inpatient admission — the patient fell out of bed at home, or fell out of bed in the emergency room prior to admission. Assign N for any external cause code representing a cause of morbidity that occurred during the inpatient hospitalisation — the patient fell out of a hospital bed during the stay, or experienced an adverse reaction to a medication administered after inpatient admission |
Practice questions#
Q1A patient develops chest pain in the emergency department and is then admitted as an inpatient. What POA indicator applies to the condition that developed in the emergency department?
- AN
- BY
- CU
- DW
Show answer & rationale
Correct answer: B. Y
Rationale. Appendix I defines present on admission as present at the time the order for inpatient admission occurs, and states that conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery, are considered as present on admission. The assigning rules repeat this: assign Y for any condition that develops during an outpatient encounter prior to a written order for inpatient admission.
Q2A patient is admitted with COPD. On hospital day three the COPD acutely exacerbates, and a single code identifying COPD with acute exacerbation is assigned. What POA indicator applies?
- AY, because the COPD was present on admission
- BN, because at least one clinical concept was not present on admission
- CU
- DW
Show answer & rationale
Correct answer: B. N, because at least one clinical concept was not present on admission
Rationale. Appendix I, codes that contain multiple clinical concepts, directs assignment of N if at least one of the clinical concepts included in the code was not present on admission, and gives COPD with acute exacerbation where the exacerbation was not present on admission as its first worked example. Y is assigned only if all of the clinical concepts were present.
Q3A patient is admitted with pneumonia. Three days later the culture returns and the provider documents Pseudomonas as the causal organism. The combination code includes the organism. What POA indicator applies?
- AN, because the organism was not known on admission
- BY, because the infection or signs of it were present on admission
- CU
- DW
Show answer & rationale
Correct answer: B. Y, because the infection or signs of it were present on admission
Rationale. Appendix I states that for infection codes that include the causal organism, Y is assigned if the infection or signs of the infection were present on admission, even though the culture results may not be known until after admission, and uses this exact example: a patient admitted with pneumonia where the provider documents Pseudomonas as the causal organism a few days later.
Q4A newborn has a condition that developed in utero. What POA indicator applies?
- AN
- BY
- CBlank
- DU
Show answer & rationale
Correct answer: B. Y
Rationale. Appendix I states that newborns are not considered to be admitted until after birth, and therefore any condition present at birth or that developed in utero is considered present at admission and should be assigned Y — including conditions that occur during delivery, such as injury during delivery, meconium aspiration, and exposure to streptococcus B in the vaginal canal.
Q5The documentation does not indicate whether a condition was present on admission and the provider is not available. What indicator applies, and what should the coder do?
- AW, and take no further action
- BU, which should not be routinely assigned — query the provider
- CN, as the safest default
- DLeave the field blank
Show answer & rationale
Correct answer: B. U, which should not be routinely assigned — query the provider
Rationale. Appendix I directs assignment of U when the medical record documentation is unclear as to whether the condition was present on admission, states that U should not be routinely assigned and should be used only in very limited circumstances, and encourages coders to query the provider when the documentation is unclear. W is reserved for the different situation where the documentation states that it cannot be clinically determined. Leaving the field blank is permitted only for codes on the exempt list.
Scenarios#
A patient is admitted after falling at home and sustaining a hip fracture. On hospital day four she falls from her hospital bed and sustains a contusion of the forearm.
Show coded answer & rationale
| Seq | Code | Description |
|---|---|---|
| 1 | Hip fracture + external cause | POA Y — the fall occurred prior to inpatient admission |
| 2 | Forearm contusion + external cause | POA N — the fall occurred during the inpatient hospitalisation |
Rationale. Appendix I, external cause of injury codes, directs assignment of Y for any external cause code representing a cause of morbidity that occurred prior to inpatient admission, using the example of a patient who fell out of bed at home or in the emergency room prior to admission, and N for any external cause code representing a cause that occurred during the inpatient hospitalisation, using the example of a patient who fell out of a hospital bed during the stay. The POA indicator follows the diagnosis code it belongs to, and external cause codes carry their own indicator.
Guideline: Appendix I
A patient with pre-existing chronic hypertension is admitted in labour. She develops pre-eclampsia during the admission, and a code from category O11, pre-existing hypertension with pre-eclampsia, is assigned.
Show coded answer & rationale
| Seq | Code | Description |
|---|---|---|
| 1 | O11.- | POA N — because one of the diagnoses identified by the code, the pre-eclampsia, was not present on admission |
| 2 | Z37.- | the outcome of delivery code, with its own indicator per the exempt list |
Rationale. Appendix I, obstetrical conditions, states that if the obstetrical code includes more than one diagnosis and any of the diagnoses identified by the code were not present on admission, assign N, and names category O11 pre-existing hypertension with pre-eclampsia as its example. It also states that whether or not the patient delivers during the current hospitalisation does not affect the POA assignment — what matters is whether the condition described by the code was present at the time of admission.
Guideline: Appendix I
A patient admitted for an acute condition is found on day two to have previously undiagnosed type 2 diabetes mellitus. The provider documents it as a new diagnosis made during the stay.
Show coded answer & rationale
| Seq | Code | Description |
|---|---|---|
| 1 | E11.9 | POA Y |
Rationale. Appendix I, acute and chronic conditions, directs assignment of Y for chronic conditions even though the condition may not be diagnosed until after admission. Appendix I also states separately that there is no required timeframe for a provider to identify or document a condition as present on admission, and that a delay in reaching a definitive diagnosis does not mean the condition was not present on admission. The diabetes existed before the admission order; only its recognition came later.
Guideline: Appendix I
Primary sources#
- ICD-10-CM Official Guidelines for Coding and Reporting, FY 2027CMS — the source document for every page on this site (effective 1 Oct 2026)
- NCHS ICD-10-CM files — Tabular List, Index, POA exempt listOfficial code files, addenda and the list of codes exempt from POA reporting
- ICD-10 Coordination and Maintenance CommitteeWhere code proposals are debated; agendas, summaries and meeting materials
- CMS ICD-10 homeCode sets, transition guidance and Medicare coding policy
- AHA Coding ClinicOfficial coding advice from the AHA Central Office — subscription required
- HHS OIG Work PlanActive audit topics — useful for prioritising internal coding audits
- MEDESUN Medical Coding AcademyTraining, credential preparation and audit services by the author