Anesthesia Coding Alert

Tip: Document the one that applies, even if you won’t be reimbursed.

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 a constant 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)

Having broad-based descriptors for P modifiers is intentional, so they can easily apply to any scenario. However, broad definitions also can complicate things from a coding perspective.

Here’s why: The ASA does not provide concrete definitions for physical status modifiers, which can make consistent reporting from one physician to another difficult. Using — and choosing — a P modifier is based on clinical decisions that the anesthesia provider makes for each individual patient. Read on to learn how to correctly apply these modifiers every time.

Consider These Comparisons

The ASA did publish some examples related to P modifiers a few years ago. They amended their information in October 2019, which adds some clarification to your decision making. For instance, the information explaining modifier P2 states, “Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease.” The explanation with P4 states, “Examples include (but not limited to): recent (< 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis.”

Having more details from the ASA will keep coders from relying so much on information from other sources for comparison purposes.

“This does help,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. “I know of coders who even got comparative examples from veterinary websites to help determine which level of modifier might best apply to a situation.”

Ask Providers to Clarify Distinctions

The descriptors for P modifiers seem simple enough on the surface but their interpretation can vary depending on the physician using them. For example, Physician A might consider a patient to have a mild form of a systemic disease (such as diabetes or lupus) because it has a minor effect on the patient’s tolerance of anesthesia or surgery and would therefore classify her as P2. Physician B might consider the same patient to have P3 status because of elevated blood pressure.

“The best way to handle this is to look for supporting documentation in the pre-anesthesia assessment,” advises Dennis.

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

• P1 is generally a healthy patient who presents to the anesthesiologist with minimal risks for the procedure in question.
• P2 applies to patients 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. Performing surgery on this patient could go one way or the other — life or death — but the patient will likely die without the surgery.
• P6 is for patients who are not eligible for a physical status risk increase as their organs are being kept viable for harvesting.

Pay Attention to Potential Base Unit Boosts

More complicated cases with higher overall risk 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

Caveat: Not all payers recognize and reimburse for P modifiers. But if the one to which you’re sending a claim 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.”

Your use of P modifiers will depend on the types of patients your providers see as well as 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.

Remember Documentation Counts More Than Dollars

Even if an insurer (such as Medicare) won’t reimburse additional amounts for P modifiers, Dennis recommends 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.”

Most of your anesthesiologist’s services will require a P1, P2, or P3 modifier. To use P4 or higher, you need clear documentation in the medical record to support its use. And don’t be surprised if a payer wants more information to support the claim even if your anesthesiologist classifies a patient as P3.

Example: A patient with stable angina would be considered a P3 status. This patient has a systemic disease that could kill him, but he is stable and expected to do well during the planned procedure. A patient with a P4 status, by contrast, has his life constantly threatened by his disease. The P4 patient isn’t expected to die in the perioperative period, although it wouldn’t be totally unexpected if it happens. Someone with unstable angina, or in congestive heart failure who needs surgery, would qualify for P4.

“One problem can be when the anesthesia provider indicates a certain P status on the charge ticket or super bill and another on the anesthesia record,” Dennis warns. “I’ll often see discrepancies when I’m auditing. If the modifiers don’t match, the anesthesia record trumps the other as long as you have clear supporting documentation.”