Anesthesia Coding Alert

"Higher carrier reimbursement for anesthesia procedures requires clarification of the complexity or level of anesthesia beyond the standard reporting codes
(00100 -01999). Understanding and appropriately appending one of six physical status modifiers (P1-P6) that describe a patients condition can determine whether and how much a carrier will reimburse. But coding that is backed up by solid documentation specific, backup information that supports using a higher physical status code will secure the highest payment.

Document, Document, Document

Think about documentation when you start a patients case history says Scott Groudine, MD, an anesthesiologist in Albany, N.Y. He believes that anesthesiologists should always have P documentation whether or not you bill for it. An anesthesia preoperative note must have certain things, including a patients physical status, Groudine explains. I assign all my patients a physical status code, irrespective of insurance or billing concerns, and its in the case notes.

The codes that will bring higher reimbursement are P3 through P5 (P-3, a patient with severe systemic disease; P-4, a patient with severe systemic disease that is a constant threat to life; P-5, a moribund patient who is not expected to survive without the operation). Complicating factors, such as unstable angina, cancer, severe pulmonary disease, previous vascular surgery, or vascular problems, make these patients a higher risk for anesthesia. P1 and P2 patients do not bring higher pay because they are in normal health or have mild systemic disease (such as arthritis, asthma, or noninsulin dependent diabetes) and their anesthesia risk level is relatively low. P6 should not be used because the patient is brain-dead.

As you code, be aware that disparity reigns in carriers policies for higher-level P code payment. To avoid rejection, check first. Some examples: Workers compensation and no-fault insurance carriers in New York state pay for physical status modifiers. Medicare and some other carriers do not. Medicaid carriers in California, Virginia, and some other states dont reimburse for higher physical status codes. And, Meridian, a major carrier in the Midwest and West, refuses reimbursement of additional money for physical status or other qualifying anesthesia codes used with Medicare patients.

Choosing a P modifier seems straightforward. But documentation might be a bit more complicated. Using a solid and specific secondary diagnosis code or sometimes even a third helps justify using higher-level P codes with patients, says Debra Hogman, billing coordinator for the physician group Affiliated Anesthesiologists in Memphis, Tenn. For example, with most carriers, reporting a gallbladder procedure for a patient with unstable angina as diagnosis code 575.10 (cholecystitis, unspecified) will not justify appending a higher-level P code. For higher payment, you would need to add the secondary diagnosis code for the coexisting problem because it is the true justifier for the higher P level. In this case the secondary code would be 411.1 (intermediate coronary syndrome), which includes the diagnosis of unstable angina.

To make matters even more complex, carriers might have preferences as to which secondary and tertiary diagnoses are solid enough to justify coding higher physical status. For example, some carriers require three diagnoses for codes P3 and higher, but will not accept hypertension, morbid obesity or obesity as secondary diagnoses. However, they do accept more specific diagnoses such as anemia, asthma, arthritis or hypothyroidism.

Find Out Who Pays and Who Doesnt

Despite these variances, anesthesia providers do well with carriers who pay for P codes. A patient classified as P3 typically merits one additional unit of anesthesia added to the startup fee, P4 two, and P5 three. We bill all carriers, with the exception of Medicare, for P modifiers, Hogman says. Once you know a carrier pays for higher-level codes, document solidly to justify their use.