Determining place of service from the ED
Q: I have a question regarding which place of service (POS) code I should use for an orthopedic doctor who did a consultation on a patient that came through the ED. The patient has a spiral fracture of the humerus. The electronic record documents that the patient was admitted to the medical unit on January 31 but was a “boarder” in the ED until February 2, waiting on a room to be available. The orthopedic doctor saw the patient on February 1. The patient did finally receive a room assignment on February 2. In this scenario would I use POS 22 (outpatient hospital) or 23 (ED)? This patient has Medicare.
A: Based on the scenario provided, the patient presented to the ED on January 31 and after examination, the determination was made to admit the patient as an inpatient. Based on the information provided, there would be an order dated January 31 to admit the patient. Because of no available bed in an inpatient unit, the patient physically remained in the ED until a bed became available on February 2. The physical location of the patient does not change the fact that the patient has been admitted (registered) as an inpatient.
According to the Medicare Claims Processing Manual, chapter 26, section 10.5, the POS is determined based on the patient’s registration status at the time that the physician sees the patient. CMS utilizes the term “registered inpatient” and notes that the POS is important for payment at the facility rate:
When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility.
In your example, you would use POS 21 (inpatient hospital), because the patient was a registered inpatient of the hospital at the time the physician provided the consultation.
Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.