Anesthesia Coding Alert

One of the first things anesthesia coders learn is the importance of including physical status modifiers (or P modifiers) on claims to document the patient's health status when entering surgery. Although P modifiers are considered informational and won't always affect reimbursement, using them helps document the procedure's complexity based on the patient's health.

The breakdown: The modifiers reflect the six rankings of patient physical status from the American Society of Anesthesiologists:  

• 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).

The challenge: The American Society of Anesthesiologists (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 the anesthesia provider makes for each patient.

Work With Your Providers on Clear 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.

"Even though the criteria are set they don't come across the same," says coding educator and auditor Leslie Johnson, CPC. "The variance in schools, professors teaching physicians, and localities can make a world of difference in how physicians perceive the physical status of each patient. An MVA patient with head trauma can be coded as P4 or P5 but have no diagnosis to support that level. Yes, the patient could die from the head trauma, but does the patient have a systemic diagnosis? The variety of diagnoses the patient and the physician's thinking can create hectic coding situations."

"The ASA finally published something about a year ago that helps define P modifiers to a certain extent," says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. The explanations are still somewhat general, but, "The ASA resource is helpful in understanding which comorbidities fall under each P status," Dennis adds. "The best way to handle this is to look for supporting documentation in the pre-anesthesia assessment."

One guideline: When reporting P3 or P4, think of these modifiers as representing a moderate to constant threat to the patient's life when he or she undergoes surgery. Modifier P5 represents a patient who is considered rather sickly. The surgery could go one way or the other – life or death – but without the surgery the patient will likely die.

Bank on Better Documentation for P3 and Higher

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. Even if your anesthesiologist classifies a patient as P3, many payers will want more information to support the claim.

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. "The anesthesia record trumps the other as long as you have clear supporting documentation."

Final note: Medicare and most other government carriers do not allow reporting or payment of P modifiers. Many private payers, however, will often reimburse for P modifiers if you follow their guidelines.