Anesthesia Coding Alert

Extra units can add up if insurers are willing to pay.

Physical status modifiers help explain a patient's health condition to insurers and better document the work an anesthesia provider does. The Anesthesia Guidelines in CPT® include the six modifiers (also known as P modifiers), consistent with the American Society of Anesthesiologists' (ASA) rankings of patient physical status. They are:

• P1 – A normal healthy patient
• P2 – A patient with mild systemic disease
• P3 – A patient with severe systemic disease
• P4 – A patient with severe systemic disease that is aconstant threat to life
• P5 – A moribund patient who is not expected to survive without the operation
• P6 – A declared brain-dead patient whose organs are being removed for donor purposes.

Understand What Each Level Can Represent

The descriptors for the P modifiers are rather broad-based. This can make being consistent when distinguishing one level from another tricky because even the ASA does not fully define the terms. Instead, using one modifier versus another is based on clinical decisions anesthesia providers make for each patient – because each patient and each situation is different.

"The ASA only started defining this a few years ago when Cleveland Clinic added a table explaining the differences," says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. "The tricky part before the table existed was that anesthesia providers often picked different physical status codes, even when given the same clinical information about a patient."

Anesthesia providers assign the patient's physical status modifier during the pre-anesthesia assessment. The followingexamples can serve as a guide to patients' conditions when you study your own providers' cases:

• P1 is generally a healthypatient who presents to the anesthesiologist with minimal risks for the procedure in question.
• P2 applies topatients with mild systemic conditions such as controlled diabetes.
• P3 applies to patients who have a severe systemic disease that could potentially kill him, such as severe diabetes with vascular complications, stable angina, or lupus. However, he is expected to do well in surgery despite the health condition.
• P4 represents a patient whose systemic disease is a higher-level threat, such as unstable angina or congestive heart failure. He isn't expected to die during the perioperative period, though having the disease means it wouldn't be totally unexpected if it happened.
• P5 represents a very high risk, sick patient or one in a trauma situation. Modifier P5 can apply to patients with severe conditions such as a ruptured aneurysm or major cerebral trauma with rapidly increasing intracranial shock.
• P6 is for patients who are not eligible for a physical status risk increase as their organs are being kept viable for harvesting.

Watch for Potential Base Unit Boosts

Higher risk, more complicated cases lead to additional risks associated with anesthesia care. Some of the P modifiers carry base unit values that reflect the level of potential risk for patients in that category:

• P1 – 0 units
• P2 – 0 units
• P3 – 1 unit
• P4 – 2 units
• P5 – 3 units
• P6 – 0 units.

Not all payers recognize and reimburse for P modifiers. But if the one you're sending a claim to does, you can add the corresponding number of base units to your calculations for a patient classified as P3, P4, or P5.

"Traditional Medicare doesn't pay for physical status modifiers," Dennis says. "Some private payers, state Medicaid, and Medicare Replacement Plans will allow extra reimbursement for levels P3 through P5."

Think about it: Your use of P modifiers will depend on the types of patients your providers see because assigning physical status is very individualized. Their use also can depend on the types of facilities where your providers practice. For example, a trauma center or other facility that handles high numbers of very sick patients will likely have more claims with patients classified as P3, P4, or P5.

Think 'Document' More Than 'Dollars'

Even if an insurer won't reimburse additional amounts for P modifiers, Dennis and other consultants recommend you still keep track of them.

"I don't recommend including them on all claims, as there are some payers that may deny," she says. "I do think it's a good idea to have the physical status in the software system for reporting and tracking purposes."

Also keep in mind that some of your providers will be better at documenting conditionsto support physical status than others. If you have questions, check with your anesthesiologist or other anesthesia provider for clarification.