CurrentColorado Rocky Mountain Health PlansPolicy 2025R9014A

Hospital-Acquired Conditions (HAC) and Present on Admission (POA) Reporting for UB-04 Claims

Defines UnitedHealthcare Medicare Advantage reimbursement stance and billing requirements for hospital-acquired conditions and Present on Admission indicators on UB-04 (institutional) claims for Medicare Advantage plans and network providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHospital-Acquired Conditions (HAC) and Present on Admission (POA) Reporting for UB-04 Claims

Policy CodePolicy 2025R9014A

Change TypeNo material changes

Effective Date

Next Review DateNov 1, 2025

Key ActionSubmit accurate UB-04 claims with POA indicators assigned for principal and secondary diagnoses per UB-04 specifications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14HAC categories listed

POA requiredPOA reporting mandate

UB-04Claim form applicability

Some hospitalsPOA exemptions

HAC and POA Coverage Rules

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HAC/POA coverage and billing rules

Payment for HACs and Present on Admission (POA) reporting requirements for IPPS hospitals.

UnitedHealthcare Medicare Advantage will not pay for selected Hospital-Acquired Conditions (HACs) if they were not present on admission; cases will be paid as though the secondary diagnosis were not present.

The POA indicator reporting provision applies only to Inpatient Prospective Payment System (IPPS) hospitals.

CMS required hospitals to report POA information for both principal and secondary diagnoses for discharges on or after October 1, 2007; UnitedHealthcare Medicare Advantage follows this reporting requirement.

Payment implications for HACs began for discharges on or after October 1, 2008; for those discharges, no additional payment will be made when a selected HAC was not present on admission.

HAC List, POA Indicators, and Effective Date

HAC Categories (01-14)ICD-10Covered

01	Foreign Object Retained Following Surgery
02	Air Embolism
03	Blood Incompatibility
04	Stage III and IV Pressure Ulcers
05	Falls and Trauma
06	Catheter-Associated Urinary Tract Infection (UTI)
07	Vascular Catheter-Associated Infection
08	Surgical Site Infection (SSI) - Mediastinitis Following Coronary Artery Bypass Graft (CABG)
09	Manifestations of Poor Glycemic Control
10	Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) With Total Knee or Hip Replacement

1–10 of 14

1/2

CMS POA Indicator Optionsmixed

Y	Diagnosis was present at time of inpatient admission — Payment is made for condition when an HAC is present.
N	Diagnosis was not present at time of inpatient admission — No payment is made for condition when an HAC is present.
U	Documentation insufficient to determine if condition was present at time of inpatient admission — No payment is made for condition when an HAC is present.
W	Clinically undetermined — Provider unable to clinically determine whether the condition was present at time of inpatient admission — Payment is made for condition when an HAC is present.
1	Unreported/Not used. Exempt from POA reporting. Equivalent of a blank on UB-04. NOTE: The '1' POA indicator should not be applied to any codes on the HAC list.

Effective Date for HAC Payment Provision

Effective DateFor discharges on or after October 1, 2008, hospitals will not receive additional payment for cases in which a selected HAC was not present on admission; the case is paid as though the secondary diagnosis were not present. POA reporting required for IPPS hospitals; CMS required POA reporting for primary and secondary diagnoses for discharges on or after October 1, 2007.

Claims Submission & Reimbursement Impact

Billing Rule

Claims submission responsibility and applicability

You are responsible for submitting accurate claims using industry-standard coding guidelines. This policy applies to institutional claims billed on the UB-04 (CMS-1450) or its electronic equivalent. Reimbursement determinations are based on the code(s) that correctly describe the services provided and may be influenced by coding methodology, regulatory requirements, benefits design, contract terms, and other applicable reimbursement policies.

Submit accurate UB-04 claims (paper FL67 and FL67A-Q for diagnoses) or electronic 837I equivalent.
This policy applies to UB-04 institutional claims (CMS-1450) and their electronic successors.

Documentation Required

POA reporting on claims

Report a POA (Present on Admission) indicator for the principal diagnosis and each secondary diagnosis on inpatient claims. For paper UB-04 claims, include the POA indicator as the eighth character of FL67 (principal) and FL67 A–Q (secondary diagnoses) using the valid POA codes (Y, N, U, W), leaving the field blank only if the diagnosis is exempt. For electronic claims, submit the POA indicator in the 837I Health Care Information Codes segment per the UB-04 Data Specifications Manual. Resolve any inconsistent, missing, conflicting, or unclear documentation with the provider.

POA must be assigned to principal and secondary diagnoses (and external cause codes when reported as other diagnosis).
POA is defined as present at the time the order for inpatient admission occurs; conditions developing during outpatient encounters are considered POA.
Hospitals reporting in 5010 format no longer use a POA code of '1' for POA-exempt codes (effective Jan 1, 2011).

Denial Risk

Reimbursement effect for HACs

For discharges on or after October 1, 2008, if a selected Hospital-Acquired Condition (HAC) was not present on admission, the case will not receive additional payment; it will be reimbursed as if the secondary diagnosis were not present. The POA reporting provision and associated payment impact apply to IPPS hospitals. Hospitals must report POA information for both primary and secondary diagnoses for discharges on or after October 1, 2007.

No additional payment for selected HACs not present on admission — treated as if the secondary diagnosis is absent for payment determination.
Provision applies to IPPS hospitals and affects MS-DRG assignment where HACs would otherwise be CC/MCC.

Key Terms

Hospital-Acquired Conditions (HAC) — definition and policy

DefinitionHospital-Acquired Conditions (HAC) are serious conditions that patients acquire during an inpatient hospital stay and are considered reasonably preventable using evidence-based guidelines.

Coverage stanceUnitedHealthcare Medicare Advantage will not pay for HACs acquired during hospitalization unless the condition was present on admission.

Selection criteriaSelected HACs were chosen by CMS based on being high volume and/or high cost and identified as CC/MCC in the MS-DRG grouper.

List sizeIncludes 14 HAC categories (expanded through FY2013 rule changes and migrated to ICD-10-CM HAC list effective October 1, 2015).

Present on Admission (POA) Indicator — definition and reporting

DefinitionPresent on Admission (POA) Indicator is assigned to each principal and other diagnosis to denote whether the condition was present at the time of inpatient admission (options: Y, N, U, W, or 1 for exempt).

Reporting requirementPOA indicators must be reported for principal and secondary diagnoses on UB-04 (FL67 8th digit) or electronically on the 837I per the UB-04 Data Specifications Manual; mandatory for inpatient admissions to general acute care (IPPS) hospitals.

Indicator meaningsY = present at admission; N = not present at admission; U = documentation insufficient; W = clinically undetermined; 1 = exempt/unreported (should not be applied to HAC list codes).

PurposePOA data identify conditions acquired during hospitalization for HAC payment adjustments and for public health uses of Medicare data.