Anesthesia Coding Alert

Physical status modifiers, also referred to as P modifiers, PS modifiers, ASAs or ASA P codes, are an important element of your anesthesia coding. If you don't use them correctly, you could dash your reimbursement opportunities, or risk a payer audit.

If your anesthesiologist works with a number of Medicare patients, you probably haven't spent much time learning the finer points of anesthesia's Physical Status Modifiers. Why? Because Medicare does not pay for them.

End of story, right? Not if your practice contracts with private payers. Many private payers will often reimburse for P modifiers if you follow the guidelines.

"Reporting is dependent on the carrier and can be dependent on whether the group negotiated for it in their contract. Most government payers do not allow reporting or payment of PS modifiers," says Debbie Farmer, CPC, ACS-AN, coder with Auditing for Compliance & Education in Leawood, Kan.

Example: A 2001 Aetna anesthesia policies memo states, "When these modifiers/codes are reported, additional ASA units may be allowed and combined with the base unit value for the anesthesia service performed." While the trick is in meeting those conditions, you don't have to shy away from P modifiers if you know the basics.

The American Society of Anesthesiologists (ASA) developed physical status modifiers to allow coders to distinguish between different levels of complexity of anesthesia service. These levels are based on the patient's condition, as follows:

• P1 -- Normal healthy patient

• P2 -- Patient with mild systemic disease

• P3 -- Patient with moderate systemic disease which can be a threat to life

• P4 -- Patient with severe systemic disease that is a constant threat to life

• P5 -- Moribund patient who is not expected to survive with or without the operation

• P6 -- Declared brain-dead patient whose organs are being removed for donor purposes.

The ASA does not provide concrete definitions for physical status modifiers because their use is based on clinical decisions the anesthesia provider makes for each patient.

Hint: Most of your anesthesiologist's services require a P1, P2, or P3 modifier. To use P4 or higher, you need clear documentation in the medical record to support its use. Even if your anesthesiologist classifies a patient as P3, many payers will want more information to supportthe claim.

How it works: 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.

A patient with a P4 status has his life constantly threatened by his disease. "ASA 4's are patients who are not expected to die in the perioperative period, although it wouldn't be totally unexpected if they do," says Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York. Someone with unstable angina, or in congestive heart failure who needs surgery, would be a 4.

In its "Revised Hospital Anesthesia Services Interpretive Guidelines," CMS offers clarification on minimum accepted standards of what should be included in a pre-anesthesia evaluation of a patient, including "notation of anesthesia risk according to established standards of practice (e.g. ASA classification of risk)."

Why it's important: The preop note should regularly include PS classification, Groudine says. If it doesn't, your practice may not be complying with CMS rules.

The best way to ensure you're using the proper PS code is to check, and double-check, your physician's documentation. In many cases you can find the ASA classification included in the operating room nurse's notes.

Heads up: "Many times I see that a claim went in without a diagnosis to support the underlying condition for reporting the PS modifier and the carrier will not allow the additional unit," Farmer says.

Note: You cannot use a PS code with an add-on code such as +01953 (Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area [TBSA] treated during anesthesia and surgery; each additional 9% total body surface area or part thereof).