Anesthesia Coding Alert

Caveat: Only report these mods for payers who’ll reimburse.

Physical status modifiers — also known as P modifiers — are unique to anesthesia coding and an important part of each claim you submit. Anesthesia providers assign P modifiers to designate the patient’s general category of health prior to a procedure. Because physical status can affect the risk of administering anesthesia, P modifiers can help document a patient’s need for anesthesia or justify the anesthesia provider’s choices.

Although the modifiers primarily are used for documentation purposes, some insurers might pay additional units to anesthesia providers when patients are assigned a higher-acuity status. That’s why coders should always pay attention to P modifier assignments and adapt their coding accordingly.

Understand What Each Designation Means

Rankings or patient physical status are designated by six P modifiers, consistent with American Society of Anesthesiologists (ASA) guidance. 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)

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

Here’s why: Having broad-based descriptors for P modifiers is intentional, so they can easily apply to any scenario. However, not having concrete definitions 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.

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 the patient as P2. Physician B might consider the same patient to have P3 status because of elevated blood pressure.

Anesthesia providers assign the patient’s physical status modifier during the pre-anesthesia assessment. Because of this, “the best way to handle this is to look for supporting documentation in the pre-anesthesia assessment,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

The ASA amended its information in October 2019 to provide some examples related to P modifiers and add some clarification to your decision making.

Examples: 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 [diabetes mellitus/hypertension], mild lung disease.” The explanation with P4 states, “Examples include (but not limited to): recent (< 3 months) MI [myocardial infarction], CVA [cerebrovascular accident], TIA [transient ischemic attack], or CAD [coronary artery disease]/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC [disseminated intravascular coagulation], ARD [acute respiratory distress] or ESRD [end stage renal disease] not undergoing regularly scheduled dialysis.”

Value Documentation Over Reimbursement

Each P modifier is assigned a unit value, as follows:

• P1 – 0 units
• P2 – 0 units
• P3 – 1 unit
• P4 – 2 units
• P5 – 3 units
• P6 – 0 units

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

“I don’t recommend including them on all claims, as there are some payers that may deny,” Dennis adds. “I do think it’s a good idea to have the physical status in the software system for reporting and tracking purposes.”

Unless your patient population is normally presenting with higher risk situations (such as patients being treated in a trauma center), most of your anesthesia provider’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 cause death, 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.

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