CurrentUnitedHealthcarePolicy 2025R9014A

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

Governs UB-04 (CMS 1450) inpatient claim reporting of Present on Admission indicators and reimbursement treatment of Hospital-Acquired Conditions for UnitedHealthcare Medicare Advantage plans and affected acute care hospitals.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy 2025R9014A

Change TypeNo material change

Effective Date

Next Review DateNov 1, 2025

Key ActionSubmit accurate UB-04 claims and report POA indicators for inpatient admissions to general acute care hospitals.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14HAC categories listed

POA requiredPOA reporting requirement

Effective Oct 1, 2008HAC payment implication

ICD-10 Oct 1, 2015Coding update

Y,N,U,W,1POA indicator options

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Reimbursement & POA Reporting Rules

HAC/POA reimbursement and reporting rules

Reimbursement rules for HACs and POA reporting:

UnitedHealthcare Medicare Advantage will not pay additional MS-DRG payment for selected Hospital-Acquired Conditions (HACs) that were not present on admission for discharges on or after Oct 1, 2008.

The case will be paid as though the secondary diagnosis were not present when a selected HAC is not present on admission.

Present on Admission (POA) indicators are required to be reported for both principal and secondary diagnoses for applicable inpatient claims; CMS required POA reporting for discharges on or after Oct 1, 2007.

The POA reporting provision applies to hospitals paid under the Inpatient Prospective Payment System (IPPS).

UnitedHealthcare Medicare Advantage follows CMS identification of HACs (including the expanded 14-category ICD-10-CM v33 list effective Oct 1, 2015) and aligns reimbursement treatment with CMS IPPS rules.

HAC and POA Coding Details

Hospital-Acquired Conditions (HAC)ICD-10Covered

HAC List (ICD-10-CM v33)

Fourteen HAC categories used to determine nonpayment if not present on admission (see list: 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; 11- Surgical Site Infection (SSI) Following Bariatric Surgery for Obesity; 12- Surgical Site Infection (SSI) Following Certain Orthopedic Procedures of Spine, Neck, Shoulder or Elbow; 13- Surgical Site Infection (SSI) Following Cardiac Implantable Electronic Device (CIED) Procedures; 14- Iatrogenic Pneumothorax w/ Venous Catheterization).

Present on Admission (POA) indicatorsmixed

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 the UB-04). Note: the '1' POA indicator should not be applied to any codes on the HAC list.

Reimbursement impact

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).

ScopeApplies to inpatient discharges subject to IPPS (UnitedHealthcare Medicare Advantage aligns with CMS reimbursement treatment).

Payment effectNo additional MS-DRG payment for HACs not present on admission; treated as if the secondary diagnosis were absent.

POA reporting relationPOA reporting is used to determine whether HAC payment reductions apply; lack of POA for a HAC triggers nonpayment per the reimbursement rule.

Claims Submission Responsibilities

Documentation Required

Claims submission responsibilities — accurate UB-04 claims and POA reporting

Submit accurate UB-04 (CMS 1450) claims and report POA indicators for inpatient admissions to general acute care hospitals; ensure claims reflect the codes that correctly describe services provided and follow UB-04 reporting specifications. UnitedHealthcare Medicare Advantage may use reasonable discretion in interpreting and applying this policy and may modify it to align with CMS changes.

You are responsible for submission of accurate claims that reflect the code(s) that correctly describe the health care services provided (see policy applicability).
This reimbursement policy applies to services billed on UB-04 forms (CMS 1450) or electronic equivalent; POA indicators must be reported per UB-04/837I specifications.
UnitedHealthcare Medicare Advantage may use reasonable discretion in interpreting and applying this policy and may update the policy to align with CMS or coding guidance.

Key Terms

HAC (Hospital-Acquired Condition)

DefinitionHospital-Acquired Condition (HAC): serious conditions acquired during an inpatient hospital stay identified by CMS as reasonably preventable and targeted for payment reductions.

HAC listFourteen HAC categories are specified (includes categories added through IPPS FY2013 such as Surgical Site Infection following CIED and Iatrogenic Pneumothorax with Venous Catheterization).

Prevention focusSelected HACs were chosen because they are high-volume and/or high-cost and are considered reasonably preventable using evidence-based guidelines.

Payment policyUnitedHealthcare Medicare Advantage will not pay for HACs acquired in the hospital unless they were present on admission.

POA Indicator

DefinitionPresent on Admission (POA) Indicator: a code applied to each principal and secondary diagnosis to indicate whether the condition was present at the time of inpatient admission (options: Y, N, U, W, or 1).