Implementation of Strategies to Improve Documentation of CMS Present on Admission Conditions

1Staten Island University Hospital, Staten Island, NY

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 127


Starting in October 2008, the Center for Medicare and Medicaid Services (CMS) mandated no longer paying for treatment costs of certain conditions deemed preventable unless documentation and coding reflecting that those conditions were present on admission (POA). Hospitals nationwide are tackling with these mandates. The areas under consideration currently include surgical site infections, catheter‐associated bloodstream infections, urinary tract infections (UTIs), and pressure ulcers. Physicians in general and hospitalists in particular play a critical role in this endeavor because documentation of these conditions in the medical record is paramount. Only complete and accurate documentation will allow coders to select the appropriate indicator to use when billing Medicare, resulting in appropriate hospital reimbursement.


The goals of this study were to develop and implement strategies to elicit POA diagnoses and to assure adequate documentation by physicians with the assistance of case managers, hospitaiists, coders, house staff, emergency room physicians and an electronic medical record in a 700‐bed community teaching hospital.


The following strategies were implemented in order to adhere to the POA guidelines. (1) attending physicians and house staff were educated about CMS guidelines via a 1‐hour presentation while coders attended a 2‐hour audio CMS course. (2) Coders were asked to screen medical charts and generate reminders via the medical record system to alert physicians regarding documentation gaps. (3) Dedicated case managers/documentation specialists were hired to review new admissions and check for adequate documentation of POA. If there is a gap in documentation, they will notify the physician directly or place a bright yellow form in the chart indicating the deficiency. (4) A POA checklist that includes the presence of decubiti, Foley catheter‐related UTI, and catheter‐related bloodstream infection was inserted in the emergency department admission template. (5) A list of the POA diagnoses are included in the history and physical template so that house staff can check off appropriate conditions. (6) During 8 am morning multi‐disciplinary rounds, attention is devoted daily to decubiti, removal of unnecessary Foley catheters, and prophylaxis of deep venous thrombosis. At present, only anecdotal outcome data are available. A preliminary chart review has shown that physicians are checking off boxes and complying with alerts by case management regarding gaps in documentation.


Our strategies are a model to assist other hospital systems with adhering to the CMS guidelines. As more POA conditions are being added to the list and tighter regulations are mandated by insurance providers, we fully expect this to be a key concern both for hospitals and hospital‐based physicians.

Author Disclosure:

M. Patel, none; T. Abdallah, none; A. Gottesman, none.

To cite this abstract:

Patel M. Implementation of Strategies to Improve Documentation of CMS Present on Admission Conditions. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 127. Journal of Hospital Medicine. 2009; 4 (suppl 1). Accessed April 8, 2020.

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