MedicaidAdministrativeHigh impact
Newsletter Vol. 22, No. 09
New Jersey Medicaid·NJ·Provider Notice
Effective date
Apr 1, 2011
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid (NJMMIS) modified its DRG assignment logic for inpatient hospital claims effective April 1, 2011. All diagnosis codes are now included in DRG calculation except Hospital Acquired Conditions (HAC) with POA indicators 'N' or 'U'. Claims missing POA indicators or containing invalid POA values will be denied with Error Code 1312.
Action Required
By April 1, 2011 (retroactive): Billing team must ensure all inpatient claims include valid Present On Admission (POA) indicators for every diagnosis code submitted to NJMMIS. Update billing system to: (1) automatically validate POA indicators on all HIPAA claim transactions and DDE/hard copy submissions; (2) cross-reference diagnosis codes against the CMS IPPS 2009 HAC list and 2011 ICD-9-CM Official Guidelines 'Categories and Codes Exempt from POA Requirement' list; (3) flag claims with missing, invalid (indicator '1'), or incomplete POA data before submission. Train coders and providers to consistently document POA status at time of coding. Implement system logic to exclude HAC-listed diagnoses with POA indicators 'N' or 'U' from DRG grouper calculations. Claims submitted without valid POA indicators will be denied with Error Code 1312 and require resubmission.