Anesthesia Coding Alert

Question: We’re having reimbursement issues with one of our private insurers underpaying on anesthesia due to a flat rate with the 2013 policy. We were not including physical status modifiers but will start to do this. Do you recommend that we include physical status modifiers for all our payers? Have things changed for 2014?

Connecticut Subscriber

Answer: Physical status modifiers (commonly known as P modifiers) are unique to anesthesia coding. They help distinguish between the levels of complexity in providing anesthesia services based on the patient’s health circumstances. Reporting a P modifier can sometimes add an additional base unit (or units) when submitted accurately on a claim (see below). 

Acceptance of P modifiers depends on payer rules, so always follow the specific payer’s policy in this regard. Medicare, for example, does not recognize P modifiers and hasn’t for quite some time. Medicaid and private insurers might reimburse for P modifiers, but it depends on the payer and the state. It is a good idea to check these on an annual basis and remember that if the physical status modifier is not reported, it will not be paid.

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 don’t 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. 

File correctly: As a general rule, payment modifiers come first and then the informational (and non-payment) modifiers are placed in claims, unless the payer has specific guidelines that state otherwise. If you’re able to report the P modifiers, base your selection on the following definitions: 

• P1 – A normal healthy patient (0 base units) 
• P2 – A patient with mild systemic disease (0 base units) 
• P3 – A patient with severe systemic disease (1 base unit) 
• P4 – A patient with severe systemic disease that is a constant threat to life (2 base units) 
• P5 – A moribund patient who is not expected to survive without the operation (3 base units) 
• P6 – A declared brain-dead patient whose organs are being removed for donor purposes (0 base units).