General Surgery Coding Alert

Question: We rushed a patient into surgery from the emergency department. The surgeon admitted the patient to the hospital until after the surgery. Should I use POS 21 or 23 for the surgery claim?


Florida Subscriber

Answer: Remember that the hospital admission code (initial inpatient care) includes all the physician's treatment on the given date of service, starting with the very first hour of the visit. Therefore, the appropriate inpatient care code will cover the time spent in the ED. You should use POS 21 (Inpatient hospital) for any initial care the surgeon performed in the ED as well as care after admission.

For the surgery codes, you would also use POS code 21, as long as the physician admits the patient afterward. If the physician never admits the patient and performs the surgery in the ED, use POS 23 (Emergency room - hospital).

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.