Neurosurgery Coding Alert

Question: We rushed a patient into surgery from the emergency department. The physician did not admit the patient to the hospital until after the surgery. Should I use POS 21 or 23 for the surgery claim?


Utah Subscriber


Answer: Remember that the hospital admission code (initial inpatient care) includes all the surgeon'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 place of service (POS) 21 (Inpatient hospital) for any initial care the physician 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 emergency department, you should use POS 23 (Emergency room - hospital).