Anesthesia Coding Alert

Question: Where should I find supporting documentation for a P3 patient? Can I use information from the patient's medical history and the review of systems?


Pennsylvania Subscriber

Answer: The physician is responsible for determining a patient's physical status level. Medicare doesn't reimburse for physical status, but some private carriers do.

If the doctor classifies a patient as P3 (A patient with severe systemic disease) or higher, most carriers want to know why. Listing multiple diagnoses (such as diabetes, hypertension, renal failure or asthma) in these cases can help to justify the physical status level. You can generally find these diagnoses in the -Preanesthetic evaluation- section of the anesthesia record.

For example, a patient has bypass surgery for ASHD (arteriosclerotic heart disease). The anesthesiologist classifies the patient as P3 because he has multiple health concerns. List any other diagnoses (diabetes, peripheral vascular disease, arthritis, etc.) to justify the P3 status.