Anesthesia Coding Alert

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

One aspect of anesthesia coding that sets it apart from other specialties is the use of physical status modifiers — also known as P modifiers — to help communicate the patient’s health status and document their preanesthesia medical comorbidities.

“This clinical tool for classifying a patient’s preoperative surgical risk was adopted in the 1970s by the [American Society of Anesthesiologists] ASA, as a way of indicating the complexity of anesthesia and justifying additional payment by insurance,” notes Tony Mira, interim CEO and vice chairman, Board of Directors at Coronis Health.

While the modifiers are mainly used for documentation purposes, some insurers might pay additional units to anesthesia providers when patients are assigned a higher-risk status. Plus, using them enhances claim accuracy and better shows the care provided. That’s why you should always pay attention to P-modifier assignments and adapt your coding accordingly.

Use 6 Levels To Define Patient Status

Although it’s primarily up to the physician to determine which P modifier to use in a particular case, coders should still check the documentation and be familiar with local guidelines to ensure they’re applying these modifiers correctly.

The anesthesia guidelines in CPT^® list six P modifiers consistent with the ASA rankings of patient physical status. Many patients fall into category P1 (A normal healthy patient) or P2 (A patient with mild systemic disease); these two modifiers are self-explanatory and don’t require additional documentation. But the records of patients who are classified as P3 (A patient with severe systemic disease), P4 (A patient with severe systemic disease that is a constant threat to life), or P5 (A moribund patient who is not expected to survive without the operation) may require additional documentation or diagnosis codes to support the patient’s status. This is because payers may reimburse at a higher rate due to the risk factors associated with treating these patients. However, additional reimbursement does not come into play with patients classified as P6 (A declared brain-dead patient whose organs are being removed for donor purposes).

P-modifier descriptors are simple — which can be both a blessing and a curse from a coding perspective.

Understand What Each Level Can Represent

Anesthesiologists are required to assign the patient’s physical status modifier during the preanesthesia assessment. The descriptors for the P modifiers are rather broad-based, enabling them to easily apply to any scenario. However, not having concrete definitions can make being consistent when distinguishing one level from another tricky.

To bring more uniformity to classifications, the ASA published some examples related to P modifiers a few years ago. The information, last amended in December 2020, provides further clarification to aid in decision making.

Analysis: Having more details from the ASA, including examples for adult, pediatric, and obstetric patients, has minimized the need for coders to rely on information from other sources for comparison purposes.

The following examples in the Statement on ASA Physical Status Classification System 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 planned procedure.
• P2 applies to patients with mild systemic diseases that do not cause substantive functional limitations. The information explaining P2 states, “adult examples include, but are not limited to … current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease.”
  The statement notes that for pediatric patients, examples include (but are not limited to) “asymptomatic congenital cardiac disease, well-controlled dysrhythmias, asthma without exacerbation, well controlled epilepsy, non-insulin dependent diabetes mellitus, abnormal BMI percentile for age, mild/moderate OSA, oncologic state in remission, autism with mild limitations.”
• P3 applies to patients with substantive functional limitations due to severe systemic disease, such as adults with “poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40)” or a history (>3 months) of MI, CVA, TIA, or CAD/ stents.” Pediatric examples include “asthma with exacerbation, poorly controlled epilepsy, insulin dependent diabetes mellitus, morbid obesity,” among others, according to the statement.
  While these patients have systemic diseases that could kill them, they are stable and expected to do well during the planned procedure.
• P4 represents a patient whose systemic disease is a higher-level threat, such as adults with ongoing cardiac ischemia, severe valve dysfunction, or congestive heart failure (CHF) with severe reduction of ejection fraction, or pediatric patients with symptomatic congenital cardiac abnormality, CHF, or advanced oncologic state.
  Patients with a P4 status have their lives constantly threatened by their disease. They aren’t expected to die in 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 who’s sustained massive trauma. Modifier P5 can be applied to patients with severe conditions such as intracranial hemorrhage with mass effect, ischemic bowel, or multiple organ/system dysfunction.
• P6 is for patients who are not eligible for a physical status risk increase as their organs are being kept viable for harvesting.

Be on the Lookout for Potential Base Unit Boosts

“Insurance plans use the physical status modifiers for two main reasons,” according to Mira. “The first is to help support medical necessity for the anesthesia service … the second reason is ‘contractual carve-outs.’ If you check your managed care contracts, you will most likely find some which pay additional units per case for ASA III and above. Although reimbursement for this contractual provision makes up a very small percentage of practices’ revenue (less than 1%), it still helps the bottom line,” he maintains.

“Traditional Medicare doesn’t pay for physical status modifiers,” adds Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “Some private payers, state Medicaid, and some Medicare replacement plans will allow extra payment for levels P3 through P5.”

When you bill P modifiers, they are a separate add-on charge to the surgical procedure’s base value. As noted above, P1 and P2 do not merit additional payment. However, you can add one unit to the procedure’s base units for a patient classified as P3, two units for a P4 patient, and three units for a P5 patient.

“These payment modifiers are usually reported after medical direction modifiers, which have a higher value. However, depending on the payer, you may be asked to report a P modifier in the first position,” Dennis notes. “Best practice is to check payer policies, when available, for reporting rules,” she advises.

Focus on Documentation and the Dollars Will Follow

Even if an insurer won’t reimburse additional amounts for P modifiers, Dennis suggests 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.”

“My rule of thumb is that if the coder cannot find a specific policy, they should report physical status modifiers, with the exception of Traditional Medicare,” Dennis explains. “Insurance cannot pay for a service that isn’t reported.”

Tip: “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. “If the modifiers don’t match, the anesthesia record trumps the super bill or charge ticket as long as you have clear supporting documentation.”