A relevant 'Condition present on admission indicator' (CPoA) shall be assigned to each ICD-10-AM code recorded for an episode of care that complies with the specific guidelines for correct assignment of 'Diagnostic code (ICD-10-AM)'. The guidelines are published in the current edition of ICD-10-AM Australian Coding Standards. Sequencing of ICD-10-AM codes must comply with the Australian Coding Standards and therefore codes should not be re-sequenced in an attempt to list codes with the same CPoA values together.
Code 1 (Yes) Condition present on admission to the episode of admitted patient care
A condition previously existing or suspected on admission to the current episode of admitted patient care such as the presenting problem, a co morbidity, or chronic disease.
- A condition that has not been documented at the time of admission, but clearly did not develop after admission (e.g. newly diagnosed diabetes mellitus, malignancy and morphology).
- A previously existing condition that is exacerbated during the current episode of admitted patient care (e.g. atrial fibrillation, unstable angina).
- A condition that is suspected at the time of admission and subsequently confirmed during the current episode of admitted patient care (e.g. pneumonia, acute myocardial infarction (AMI), stroke, unstable angina).
- A condition impacting on obstetric care arising prior to admission (e.g. venous complications, maternal disproportion).
- For neonates, this also includes the condition(s) in the birth episode arising before the labour and delivery process (e.g. prematurity, birth weight, talipes, clicking hip).
- Disease status or administrative codes not arising during the episode of admitted patient care (e.g. history of tobacco use, duration of pregnancy, colostomy status).
- Outcome of delivery (Z37) and place of birth (Z38) codes.
Code 2 (No) Condition arose during the episode of admitted patient care
A condition which arose during the current episode of admitted patient care and would not have been present or suspected on admission.
- A condition resulting from misadventure during surgical or medical care in the current episode of admitted patient care (e.g. accidental laceration during procedure, foreign body left in cavity, medication infusion error).
- An abnormal reaction to, or later complication of, surgical or medical care arising during the current episode of admitted patient care (e.g. postprocedural shock, disruption of wound, catheter associated urinary tract infection (UTI)).
- A condition newly arising during the episode of admitted patient care (e.g. pneumonia, rash, confusion, UTI, hypotension, electrolyte imbalance).
- A condition impacting on obstetric care arising after admission, including complications or unsuccessful interventions of labour and delivery or prenatal/postpartum management (e.g. labour and delivery complicated by fetal heart rate anomalies, postpartum haemorrhage).
- For neonates, this also includes the condition(s) in the birth episode arising during the birth event (i.e. the labour and delivery process) (e.g. respiratory distress, jaundice, feeding problems, neonatal aspiration, conditions associated with birth trauma, newborn affected by delivery or intrauterine procedures).
- Disease status or administrative codes arising during the episode of admitted patient care (e.g. cancelled procedure, multi-resistant Staphylococcus aureus (MRSA)).
Code 9 (Unknown/Uncertain) Condition onset unknown/uncertain on admission to the episode of admitted patient care
A condition where the clinical documentation does not support assignment to code 1 or code 2.
From 2013/14, the Condition Present on Admission (CPoA) flag value 'Condition arose during the current episode of admitted patient care' (CPoA 2) has been able to be assigned against the Principal Diagnosis (PD) in certain circumstances. Where a condition has arisen during the admitted birth episode for a neonate (i.e. labour and delivery process), that condition can be flagged as arising during the episode of care and assigned CPoA 2. Examples include respiratory distress, neonatal aspiration, conditions associated with birth trauma or newborn affected by delivery or intrauterine procedures.
When a single ICD-10-AM code describes multiple concepts (i.e. a combination code) and any concept within that code meets the criteria of arising during the episode of care, assign CPoA 2.
Where multiple conditions/sites are classifiable to a single ICD-10-AM code that meets the criteria for different CPoA values, assign COF 2; excepting where the condition/site is sequenced as the principal diagnosis and must be assigned CPoA 1.
The CPoA value assigned to external cause, place of occurrence and activity codes should match that of the corresponding injury or disease code. Injuries which occur during the admitted episode of care but not on the hospital grounds (e.g. hospital in the home (HITH)) should be assigned CPoA 2 as 'arising during the episode of admitted patient care'.
The CPoA value assigned to morphology codes should match that on the corresponding neoplasm code.
The CPoA value on Z codes related to the outcome of delivery on the mother's record (Z37), or the place of birth on the baby's record (Z38) should always be assigned CPoA 1 (present on admission).
The CPoA value on aetiology and manifestation (dagger and asterisk) codes should be appropriate to each condition and therefore the dagger and asterisk codes may be assigned different CPoA values.
An episode of admitted patient care includes all periods when the patient remains admitted and under the responsibility of the health care provider, including periods of authorised leave and HITH. Where diagnoses arising during this period meet the criteria for ACS 0002 'Additional diagnoses', coders should apply the CPoA Guide for use instructions and assign CPoA 2 if appropriate. Unauthorised leave does not fall under the responsibility of the health care provider and conditions arising during this time should be assigned CPoA 1.
Where an admission has multiple admitted patient episode 'care type' changes (e.g. acute to rehabilitation), CPoA assignment should be relevant to each episode. A condition arising in an episode should be assigned CPoA 2. If care for that condition continues in subsequent episodes those conditions should be assigned CPoA 1.