Certified Inpatient Coding (CIC) Practice Exam

A patient presents with symptoms leading to a diagnosis of pneumonia prior to developing sepsis. What POA indicator should be assigned for the pneumonia diagnosis?

1. U

2. N

3. Y

4. W

The correct answer is: N

In this scenario, the diagnosis of pneumonia occurred before the onset of sepsis. The Present on Admission (POA) indicator is used in inpatient coding to determine whether a condition was present at the time of admission to the hospital or developed subsequently during the hospitalization. Assigning a POA indicator of "N" indicates that the pneumonia was not present on admission. Since the patient displayed symptoms of pneumonia prior to the diagnosis of sepsis, this means that the pneumonia was indeed present and should reflect that status. In contrast, the appropriate POA indicator that aligns with the situation where pneumonia was diagnosed before any progression to sepsis would typically be "Y," indicating that the condition was present at the time of admission. The reasoning for a POA indicator of "B" (not present on admission) does not align with the clinical context provided in the question, as it does not appropriately reflect the timeline of diagnosis. In this case, it is important for coders to accurately assign the POA indicator to reflect the true nature of the patient's condition when they were admitted, ensuring that it aligns with coding guidelines and hospital reporting standards.