UB-04 Form Locators 67 & 69: Understanding & Fixing Present On Admission (POA) Indicator Denials (Reason Code 34931)

Understanding the correct application of the POA indicator on UB04 forms is paramount for accurate hospital billing, compliant reimbursement, and avoiding costly denials. The Present On Admission (POA) indicator, primarily found in Form Locators (FL) 67 and 69, is a critical data element that communicates to payers whether a diagnosis was present at the time of inpatient admission or developed during the hospital stay. Misinterpreting or incorrectly assigning these indicators can lead to significant financial repercussions, including reduced DRG payments, denial of services, and even audit scrutiny. This comprehensive guide delves deep into the nuances of POA indicators, offering expert insights, practical examples, and actionable strategies to ensure your claims are clean, compliant, and paid promptly.

Quick Reference Guide

Navigating the complexities of POA indicators requires a clear understanding of each code’s meaning and application. This quick reference table provides an at-a-glance overview of the essential POA indicators and their implications for UB-04 billing.

POA Indicator	Description	Application	Impact on Reimbursement
Y	Yes, present at admission.	Diagnosis was unequivocally present at the time the inpatient admission began.	Generally no negative impact; diagnosis contributes to DRG as expected.
N	No, not present at admission.	Diagnosis was not present at the time of inpatient admission. It developed during the hospital stay.	May lead to reduced DRG payment if it’s a Hospital-Acquired Condition (HAC) or if it significantly impacts the DRG without being POA.
U	Unknown documentation insufficient to determine if condition was present at admission.	Clinical documentation is unclear or conflicting regarding the POA status of the diagnosis.	Treated as ‘N’ for HAC purposes by Medicare, potentially leading to reduced DRG payment. Avoid ‘U’ whenever possible.
W	Clinically undetermined. Provider unable to clinically determine whether condition was present at admission.	Used when a provider, despite thorough clinical evaluation, cannot definitively determine POA status. Rare.	Treated as ‘N’ for HAC purposes by Medicare, potentially leading to reduced DRG payment. Avoid ‘W’ whenever possible.
Blank	Exempt from POA reporting.	Certain diagnoses (e.g., external causes of morbidity, some V/Z codes) are exempt from POA reporting.	No impact on reimbursement as POA reporting is not required.

Detailed Breakdown: Mastering POA Indicators and UB-04 Form Locators

The UB-04 claim form is the standard for institutional billing, and two specific field locators are dedicated to diagnosis codes and their corresponding POA indicators: FL67 and FL69. Understanding their interplay is fundamental to compliant billing.

Where is POA Indicator on UB04? Understanding Form Locators 67 and 69

The POA indicator on UB04 is primarily found in two key areas:

• Form Locator 67 (FL67): Principal Diagnosis Code and Other Diagnoses
• Form Locator 69 (FL69): POA Indicator for Other Diagnoses

FL67 Diagnosis Code: This field is where the principal diagnosis code is entered, along with up to 24 other diagnosis codes that describe the patient’s condition and treatment during the hospital stay. Each of these diagnosis codes requires a corresponding POA indicator.

Where is present on admission indicator located on a UB? For the principal diagnosis (the first diagnosis listed in FL67), its POA indicator is typically placed immediately after the diagnosis code itself, often as a single character. For the subsequent “other diagnoses” listed in FL67, their respective POA indicators are reported in FL69, in the same order as the diagnoses appear in FL67.

It’s crucial to remember that every non-exempt diagnosis code reported on the UB-04 must have an accurate POA indicator. Failure to do so is a common reason for denials (Reason Code 34931) and can trigger audits.

Present On Admission Indicators: A Deep Dive into Y, N, U, W, and Blank

Let’s expand on the application of each POA indicator with more in-depth clinical case studies.

Indicator ‘Y’: Yes, Present at Admission

This indicator signifies that the diagnosis was present at the time the inpatient admission began. This includes conditions that developed during an outpatient encounter (e.g., in the emergency department, observation unit, or during outpatient surgery) prior to the formal inpatient admission order.

• Clinical Case Study 1: Acute Myocardial Infarction (AMI)

  A 65-year-old male presents to the Emergency Department (ED) with severe chest pain. ECG confirms ST-elevation myocardial infarction (STEMI). He is admitted directly to the cardiac catheterization lab for percutaneous coronary intervention (PCI). The diagnosis of STEMI (I21.01) would be assigned a ‘Y’ indicator because it was clearly present upon his arrival at the hospital and led to his inpatient admission.

• Clinical Case Study 2: Diabetic Ketoacidosis (DKA)

  A 28-year-old female with Type 1 Diabetes is brought to the ED by ambulance, unresponsive. Blood work reveals severe hyperglycemia and acidosis, confirming DKA (E10.10). She is admitted to the ICU. DKA is assigned a ‘Y’ indicator as it was the primary reason for her presentation and admission.

Indicator ‘N’: No, Not Present at Admission

This indicator is used when a diagnosis was not present at the time of inpatient admission but developed during the hospital stay. This is particularly critical for Hospital-Acquired Conditions (HACs).

• Clinical Case Study 1: Catheter-Associated Urinary Tract Infection (CAUTI)

  A 70-year-old patient is admitted for elective hip replacement surgery. On post-operative day 5, she develops a fever and dysuria. Urine culture confirms a urinary tract infection (UTI) caused by the indwelling Foley catheter placed on admission. The diagnosis of CAUTI (N39.0, T83.511A) would be assigned an ‘N’ indicator because it developed after admission and is a known HAC.

• Clinical Case Study 2: Post-Operative Pneumonia

  A 55-year-old patient undergoes a major abdominal surgery. Three days post-op, he develops a cough, fever, and infiltrates on chest X-ray, leading to a diagnosis of pneumonia (J18.9). If the pneumonia was not present or incubating at the time of admission, it would receive an ‘N’ indicator.

Indicator ‘U’: Unknown – Documentation Insufficient

This indicator is used when the clinical documentation is unclear, ambiguous, or conflicting, making it impossible to definitively determine if a condition was present at admission. Medicare treats ‘U’ as ‘N’ for HAC purposes, meaning it can lead to reduced reimbursement.

• Clinical Case Study: Unspecified Anemia

  A patient is admitted for a fractured femur. On day 2, labs show mild anemia (D64.9). The physician’s notes mention “anemia noted,” but there’s no clear indication if it was present on admission, if it developed due to blood loss during surgery, or if it was a pre-existing but undiagnosed condition. Without further clarification from the physician, the coder might be forced to assign ‘U’. However, a query to the physician is always preferred to clarify the POA status.

Indicator ‘W’: Clinically Undetermined

This indicator is reserved for rare situations where a provider, despite thorough clinical evaluation and diagnostic testing, cannot definitively determine the POA status of a condition. Like ‘U’, Medicare treats ‘W’ as ‘N’ for HAC purposes.

• Clinical Case Study: Atypical Presentation of Sepsis

  A patient with multiple comorbidities is admitted with vague symptoms. Over the first 24 hours, the patient’s condition deteriorates, and sepsis (A41.9) is diagnosed. Despite extensive workup and review of prior records, the medical team cannot definitively conclude if the sepsis was incubating or subtly present at admission, or if it rapidly developed post-admission due to the patient’s fragile state. This is a very rare scenario where ‘W’ might be considered, but again, physician query is paramount.

Indicator ‘Blank’: Exempt from POA Reporting

Certain diagnosis codes are exempt from POA reporting requirements. These typically include codes that describe external causes of morbidity (V, W, X, Y codes), some Z codes (factors influencing health status and contact with health services), and certain other codes as specified by CMS or other payers. For these codes, the POA field is left blank.

• Clinical Case Study: Fall from Ladder

  A patient is admitted with a fractured ankle (S82.8X1A) after falling from a ladder (W11.XXXA). The fracture code would receive a ‘Y’ indicator. However, the external cause code W11.XXXA (Fall from ladder) would be left blank as it is exempt from POA reporting.

Financial Impact of Incorrect POA Indicators on DRG Assignments and Hospital Reimbursement

The correct assignment of POA indicators has a direct and significant impact on hospital reimbursement, particularly for Medicare patients under the Inpatient Prospective Payment System (IPPS).

Hospital-Acquired Conditions (HACs) and Reduced DRG Payments

Medicare’s HAC Reduction Program identifies certain conditions that, if acquired during a hospital stay (i.e., assigned an ‘N’, ‘U’, or ‘W’ POA indicator), will not result in increased reimbursement. This means if a patient develops a condition like a CAUTI or a surgical site infection (SSI) during their stay, and that condition would normally increase the DRG payment, Medicare will pay as if the HAC never occurred. This can lead to a substantial reduction in the Diagnosis-Related Group (DRG) payment, as the hospital bears the cost of treating the HAC.

• Example: A patient is admitted for pneumonia (DRG 193). During the stay, they develop a pressure ulcer (L89.110). If the pressure ulcer is coded ‘N’ (not POA), and it’s a Stage 3 or 4 ulcer, it’s a HAC. If this pressure ulcer would have otherwise shifted the DRG to a higher-paying one (e.g., DRG 190 with major complications), Medicare will still pay at the lower DRG 193 rate, effectively penalizing the hospital for the preventable condition.

Impact on Case Mix Index (CMI)

Incorrect POA assignments, especially the overuse of ‘U’ or ‘W’ when ‘Y’ is appropriate, can artificially lower a hospital’s Case Mix Index (CMI). CMI reflects the average relative weight of a hospital’s DRGs and is a key factor in determining overall reimbursement. A lower CMI means lower overall payments for the same volume of patients.

Audits and Compliance Risks

Payers, including Medicare Administrative Contractors (MACs) and private insurers, frequently audit claims for POA indicator accuracy. Incorrect or inconsistent POA reporting can trigger extensive audits, leading to recoupments, penalties, and damage to a hospital’s reputation. Consistent and accurate POA assignment is a critical component of a robust compliance program.

Payer-Specific POA Guidelines

While Medicare sets the standard for POA reporting, it’s crucial to understand that payer-specific POA guidelines can vary significantly.

• Medicaid: Many state Medicaid programs follow Medicare’s POA guidelines, but some may have their own lists of HACs or specific reporting requirements. It’s essential to consult each state’s Medicaid provider manual.
• Commercial Payers: Private insurance companies often have their own policies regarding POA indicators. Some may adopt Medicare’s HAC list, while others may have a different set of conditions for which they will not provide additional reimbursement if not POA. Some payers may also have different rules for when ‘U’ or ‘W’ are acceptable, or how they impact payment. Always check the specific payer’s medical policies or provider agreements.
• Managed Care Organizations (MCOs): MCOs, especially those covering Medicare Advantage or Medicaid managed care, will typically adhere to the underlying program’s rules but may also impose additional administrative requirements or review processes.

Best practice dictates reviewing payer contracts and policy manuals regularly to stay updated on any unique POA reporting requirements. A robust claims scrubbing process should incorporate payer-specific edits for POA indicators.

Addressing “How to fix UB04 code [fl67] diagnosis principal code warning primary diagnosis mismatch when they match”

This specific warning indicates a discrepancy where your billing system or a payer’s editing system flags a potential mismatch between the principal diagnosis code in FL67 and its associated POA indicator, even when you believe they are correctly matched. This can be incredibly frustrating. Here’s how to troubleshoot and fix it:

1. Verify the Principal Diagnosis:
   • Double-check that the diagnosis code entered as the principal diagnosis in FL67 is indeed the condition chiefly responsible for the patient’s admission to the hospital. Review the physician’s documentation carefully.
   • Ensure there are no typos or incorrect characters in the code.
2. Verify the POA Indicator for the Principal Diagnosis:
   • Confirm that the POA indicator immediately following the principal diagnosis code is accurate based on the clinical documentation. Was this condition definitively present at admission (Y)?
   • Remember, the principal diagnosis should almost always have a ‘Y’ indicator, as it’s the reason for admission. An ‘N’ for a principal diagnosis would be highly unusual and likely incorrect, triggering an edit.
3. Check for System Edits/Logic:
   • Internal Billing System Edits: Your own billing software might have built-in edits that are flagging this. Sometimes these edits are overly sensitive or based on outdated rules. Consult your IT or billing system administrator.
   • Payer-Specific Edits: The payer’s claims processing system might have specific edits. For example, some payers might have a list of diagnoses that they never expect to see as a principal diagnosis with a ‘Y’ indicator, or vice-versa, based on their medical policies.
   • Coding Guidelines: Ensure you are adhering to the latest ICD-10-CM Official Guidelines for Coding and Reporting. Certain codes have specific sequencing rules or POA implications.
4. Review for “Unacceptable Principal Diagnoses”:
   • Some diagnoses, particularly certain symptom codes or “rule out” diagnoses, are generally not accepted as principal diagnoses by payers. If your principal diagnosis falls into this category, the system might be flagging it, even if the POA is technically correct for that code. The fix here is to identify the true underlying condition and make it the principal diagnosis.
5. Contact Payer/Clearinghouse:
   • If you’ve verified everything internally and the warning persists, contact the payer’s provider relations department or your clearinghouse support. Provide them with the exact warning message and the claim details. They can often clarify the specific edit rule that is being triggered.
6. Consider a “Blank” POA:
   • While rare for a principal diagnosis, ensure the code isn’t one that is exempt from POA reporting (e.g., certain Z codes). If it is, the system might be expecting a blank, not a ‘Y’.

Can Box 69 on UB04 be left blank?

Yes, Box 69 on UB04 can be left blank under specific circumstances. FL69 is where the POA indicators for the “other diagnoses” listed in FL67 are reported. If there are no “other diagnoses” that require POA reporting (i.e., only the principal diagnosis is reported, or all other diagnoses are exempt from POA reporting), then FL69 would be left blank. However, if you have other diagnoses in FL67 that are not exempt from POA reporting, then FL69 must contain the corresponding POA indicators. Leaving it blank for non-exempt diagnoses will result in denials for missing or invalid information.

Which Field Locator Displays the Amount of Non-Covered Charges (Not Disallowed Charges) in UB 04 Claim Form?

While not directly related to POA indicators, this is a common question regarding UB-04 form completion. The amount of non-covered charges (not disallowed charges) is displayed in Form Locator 47 (FL47) – Non-Covered Charges. It’s important to distinguish between “non-covered” and “disallowed.”

• Non-covered charges: These are services or items that are explicitly excluded from coverage by the patient’s insurance policy (e.g., cosmetic surgery, certain experimental treatments). The patient is typically responsible for these charges.
• Disallowed charges: These are charges that the payer determines are not medically necessary, are incorrectly coded, or exceed the allowed amount for a covered service. These are typically written off by the provider after adjudication.

FL47 is used to report the total amount of charges that the hospital knows, at the time of billing, are not covered by the primary payer.

POA Indicator Assignment and Denial Prevention Checklist/Flowchart

To aid in accurate POA assignment and prevent denials, consider implementing a robust internal process supported by a checklist or flowchart. While I cannot provide a downloadable file, here’s what such a tool would encompass:

POA Indicator Assignment Flowchart (Conceptual)

1. Identify All Diagnoses: List all diagnoses documented by the physician for the inpatient stay.
2. Determine Principal Diagnosis: Identify the condition chiefly responsible for the admission.
3. For Each Diagnosis (Principal & Other):
   • Step A: Was the condition present at the time of inpatient admission?
     • YES: Assign ‘Y’. (Consider if it developed during an outpatient encounter immediately preceding admission.)
     • NO: Proceed to Step B.
   • Step B: Did the condition develop during the inpatient stay?
     • YES: Assign ‘N’. (Be mindful of HACs.)
     • NO/UNCLEAR: Proceed to Step C.
   • Step C: Is documentation sufficient to determine POA status?
     • YES (and it was present): Assign ‘Y’.
     • YES (and it was not present): Assign ‘N’.
     • NO (documentation unclear/conflicting): Query the physician for clarification.
       • If physician clarifies ‘Y’: Assign ‘Y’.
       • If physician clarifies ‘N’: Assign ‘N’.
       • If physician states clinically undetermined: Assign ‘W’ (rare).
       • If physician cannot clarify and documentation remains insufficient: Assign ‘U’ (use as last resort).
   • Step D: Is the diagnosis exempt from POA reporting?
     • YES: Leave POA indicator blank.
     • NO: Ensure a ‘Y’, ‘N’, ‘U’, or ‘W’ is assigned.
4. Review and Validate: Before claim submission, review all diagnoses and their assigned POA indicators for accuracy and consistency with documentation.

Denial Prevention Checklist (Conceptual)

• ✓ All non-exempt diagnoses in FL67 have a corresponding POA indicator in FL67 (for principal) or FL69 (for others).
• ✓ POA indicators are accurately assigned based on clear clinical documentation.
• ✓ Physician queries are utilized for ambiguous documentation regarding POA status.
• ✓ Overuse of ‘U’ and ‘W’ indicators is avoided.
• ✓ Payer-specific POA guidelines have been reviewed and applied.
• ✓ Claims scrubbing software includes edits for POA indicator compliance.
• ✓ Regular training is provided to coders and billers on POA guidelines and updates.
• ✓ Internal audits of POA assignments are conducted periodically.

Real-World Billing Scenarios & Patient Status Changes

POA indicators become particularly complex when patient status changes or when conditions evolve.

Scenario 1: Observation to Inpatient Conversion

A patient is admitted to observation status for chest pain. During the 24-hour observation period, diagnostic tests confirm unstable angina. The patient is then formally admitted as an inpatient. The diagnosis of unstable angina (I20.0) would be assigned a ‘Y’ indicator because it was present at the time the inpatient admission began, even though the patient was initially in an outpatient status (observation).

Scenario 2: Transfer from Another Facility

A patient is transferred from a skilled nursing facility (SNF) to the hospital for acute worsening of a chronic wound infection. The wound infection (L03.115) was clearly present at the SNF and is the reason for the hospital admission. It would receive a ‘Y’ indicator.

Scenario 3: Condition Developing in ED Prior to Inpatient Order

A patient presents to the ED with abdominal pain. During the ED stay, imaging reveals acute appendicitis. An inpatient admission order is then written. The diagnosis of acute appendicitis (K35.80) would be assigned a ‘Y’ indicator because it was present before the formal inpatient admission order was placed, even though it was diagnosed in the ED.

Scenario 4: Elective Surgery with Post-Op Complication

A patient undergoes elective knee replacement surgery. Post-operatively, they develop deep vein thrombosis (DVT) (I82.401). If the DVT was not present or incubating at the time of admission, it would be assigned an ‘N’ indicator. This is a critical point for HACs, as DVT is on Medicare’s HAC list if not POA.

Common Denial Codes & Step-by-Step Appeal Instructions

Incorrect or missing POA indicators are a frequent cause of claim denials. Understanding the common denial codes and having a clear appeal process is vital.

Common Denial Codes Related to POA Indicators

• Reason Code 34931: This is a specific Medicare reason code indicating “Missing/Invalid POA Indicator.” This is the most direct denial related to POA.
• CARC CO-16: “Claim/service lacks information which is needed for adjudication.” This often accompanies POA issues, as the missing indicator prevents full processing.
• CARC CO-24: “Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.” While not directly POA, if a POA issue leads to a service being deemed non-covered, this could appear.
• RARC M86: “Missing/incomplete/invalid ‘present on admission’ indicator.” This is a more specific RARC (Remittance Advice Remark Code) that often accompanies CO-16 or other CARCs.
• RARC N116: “This payment adjustment is due to the provider’s failure to submit a valid POA indicator.” Another specific RARC.
• RARC N382: “The diagnosis code is inconsistent with the patient’s age or sex.” While not directly POA, if a POA issue leads to an incorrect DRG, other edits might fire.

Step-by-Step Appeal Instructions for POA Denials

When you receive a denial related to a POA indicator, a systematic approach to appeals is essential.

1. Identify the Specific Denial Reason:
   • Review the Explanation of Benefits (EOB) or Remittance Advice (RA) to pinpoint the exact CARC and RARC codes. This will tell you precisely why the claim was denied.
   • Note the specific diagnosis code(s) for which the POA indicator was flagged.
2. Review Clinical Documentation:
   • Go back to the patient’s medical record.
   • Carefully review the physician’s notes, nursing assessments, ED reports, admission history and physical, and any diagnostic test results from the time of admission and the days leading up to it.
   • Look for explicit statements about when the condition was first identified or when symptoms began.
3. Verify POA Indicator Assignment:
   • Compare the documentation with the POA indicator originally submitted on the UB-04.
   • Determine if the indicator was indeed incorrect, or if it was correct but the documentation wasn’t clear enough to support it.
4. Correct the Claim (if necessary):
   • If the POA indicator was truly incorrect (e.g., submitted ‘N’ when it should have been ‘Y’), correct the indicator.
   • If the documentation was insufficient, but you believe the condition was POA, initiate a physician query to obtain clarification. Once clarified, update the POA indicator.
5. Prepare the Appeal Letter:
   • Clear and Concise: State the patient’s name, account number, claim number, and date of service.
   • Reference Denial: Clearly state the denial reason (CARC/RARC) and the date of the denial.
   • Explain the Correction/Justification:
     • If you corrected the POA indicator, state the original indicator, the corrected indicator, and why the correction was made (e.g., “Upon review of the admission H&P, it was clearly documented that [diagnosis] was present on admission, therefore the POA indicator has been changed from ‘N’ to ‘Y’.”).
     • If the original POA was correct, but the payer misinterpreted, explain why the original POA was accurate, citing specific documentation.
   • Cite Guidelines: Reference relevant coding guidelines (e.g., ICD-10-CM Official Guidelines) or payer-specific policies that support your position.
   • Request Reconsideration: Clearly ask the payer to reprocess the claim with the corrected or clarified information.
6. Attach Supporting Documentation:
   • Include copies of relevant sections of the medical record (e.g., admission H&P, physician orders, progress notes, diagnostic reports) that support the POA status.
   • Attach the corrected UB-04

     FAQ: Common Questions Answered

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     What are the specific definitions for each POA indicator (Y, N, U, W, Blank)?

     Understanding each POA indicator is fundamental for accurate billing. Y (Yes) signifies that the diagnosis was unequivocally present at the time the inpatient admission began. N (No) indicates the diagnosis was not present at admission but developed during the hospital stay. U (Unknown) is used when the documentation is insufficient to determine if the condition was present at admission. W (Clinically Undetermined) applies when the provider is unable to clinically determine whether the condition was present at admission, even after review. A Blank indicator is typically used for diagnoses that are exempt from POA reporting, such as certain external cause of injury codes, or for outpatient encounters where POA is not applicable.

     How does an incorrect POA indicator affect DRG assignment and hospital reimbursement?

     An incorrect POA indicator can have significant financial repercussions. If a condition that was truly present on admission (POA) is incorrectly coded as ‘N’ and it’s identified as a Hospital-Acquired Condition (HAC), Medicare and many commercial payers will reduce the Diagnosis-Related Group (DRG) payment, as they will not pay for the increased costs associated with treating conditions acquired during the stay. Conversely, if a condition that developed during the stay is incorrectly marked ‘Y’ and it significantly impacts the DRG, it could lead to an overpayment that is subject to recoupment during audits, potentially incurring penalties. Even ‘U’ or ‘W’ indicators can lead to denials or payment reductions if payers require a definitive ‘Y’ or ‘N’ for certain conditions to ensure appropriate reimbursement.

     Are there any specific payer-specific guidelines for POA reporting that differ from Medicare?

     While most commercial payers largely align their POA reporting requirements with Medicare’s guidelines, particularly concerning the identification and non-payment for Hospital-Acquired Conditions (HACs), it is crucial to recognize that variations can exist. Some payers may have slightly different lists of conditions they classify as HACs, or they might have unique policies regarding the acceptance of ‘U’ or ‘W’ indicators, sometimes requiring further clarification or treating them as ‘N’ for payment purposes. Hospitals must meticulously review individual payer contracts, policy manuals, and bulletins to ensure full compliance and avoid unexpected denials or payment adjustments.

     What is the typical timeframe for resubmitting a claim after correcting a POA indicator denial?

     The timeframe for resubmitting a claim after correcting a POA indicator denial varies by payer, but generally, it falls within the payer’s timely filing limits for appeals or corrected claims. This period typically ranges from 90 to 180 days from the date of the initial denial or the remittance advice. Upon receiving a denial related to a POA indicator, hospitals should promptly review the medical record, make the necessary corrections to the POA indicator (and potentially the diagnosis code if warranted), and then resubmit the claim as an appeal or corrected claim. Adhering strictly to these timeframes is critical to prevent forfeiture of legitimate reimbursement and to maintain a healthy revenue cycle.

External Resources & Authority Links

• For more detailed insights, refer to the official CMS Medicare guidelines.
• For more detailed insights, refer to the CMS guidelines.