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Latest on Physical Status Modifiers (P1-P6) from Codify's Anesthesia Coder  

Mind Your P Modifiers or Leave Money on the Table

Use 6 Levels to Define Patient's Status

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...

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One area of coding that is unique to anesthesia is the use of physical status modifiers (P modifiers) for each patient, which are appended on claim forms after the procedure code. These modifiers distinguish between different levels of complexity of anesthesia service provided, depending on the patient's circumstances, but the distinctions between different modifiers can vary somewhat among providers. Although it's primarily up to the physician to determine which P modifier to use in a particular case, coders still should check the record's documentation and be familiar with local guidelines to ensure that they assign codes correctly.

Know the Differences Among Modifiers

CPT's anesthesia section lists six physical status modifiers which are consistent with how the American Society of Anesthesiologists (ASA) ranks patient status. Many patients fall into categories P1 (A normal healthy patient) or P2 (A patient with mild systemic disease); these two modifiers are self-explanatory and don't require additional documentation. But the records of patients who are classified as P3 (A patient with severe systemic disease) P4 (A patient with severe systemic disease that is a constant threat to life) or P5 (A moribund patient who is not expected to survive without the operation) do need documentation supporting their status. This is because insurance carriers may reimburse at a higher rate due to the risk factors associated with treating these patients. Additional reimbursement does not come into play with patients classified as P6 (A declared brain-dead patient whose organs are being removed for donor purposes).

The only reason we get extra value for patients classified as P3-P5 is the added difficulty factor in trying to ensure they survive the surgery " explains Robin Fuqua CPIC a coder for anesthesiologist Jose G. Veliz MD in Escondido Calif. "Nothing extra is paid for P6 because the patient has been ruled clinically dead. [...]

<!--more-->However the patient still must be anesthetized for organ harvesting to assure adequate perfusion of the organs until the harvested organs are removed from the body. Once this type of surgery is over all machines are turned off and the patient is no longer ventilated or supported hemodynam-ically. No carrier needs to pay extra for these procedures."

Consider these examples of conditions that can qualify for the different levels of P modifiers:

P1 No documentation of special conditions is needed for patients classified as P1 and the insurance company is not billed any additional charges.

P2 No documentation of the condition is needed for P2 patients either and the carrier is not billed. Mild forms of anemia or other conditions can qualify a patient for P2 status. Smoking also can qualify a patient as P2 because caregivers and carriers assume that he has some degree of lung disease.

P3 Patients classified as P3 may have severe anemia hypertension diabetes or a mild heart lung or circulatory disease. A patient who smokes and has lung disease that is life-threatening would also be P3.

P4 These patients have moderate to severe cases of respiratory distress trauma shock sepsis or other heart lung or circulatory disease. Unstable angina cardiogenic shock active pulmonary disease or increased intracranial pressure are a few examples of P4 conditions.

P5 Patients in the P5 category have severe heart respiratory or circulatory disease or major trauma such as an MVA (motor vehicle accident) or MCA (motorcycle accident). Other conditions including septic shock ruptured aneurysm postoperative bleeding and loss of consciousness may also qualify for P5 classification if the immediate postoperative prognosis is grave.

Get Reimbursed for Qualifying P Codes

  If the P modifier qualifies for additional reimbursement (meaning the patient is considered to be P3-P5) the payment level depends on which modifier you use. It can also depend on the patient's insurance carrier Medicare and some other payers do not pay additional fees based on physical status modifiers but others do. "HMOs usually don't pay more than the contracted rate for services so the P codes don't affect your payment " Fuqua says. Most payers that pay for P codes seem to be commercial PPO carriers according to Fuqua.

"We don't include anything on the claim about the P factor " Fuqua continues. "We just include it in the patient's record as backup so it's there if questions come up later. We've never fought with carriers over whether we're reimbursed for the P codes as long as they pay for the procedure. If anyone pays us for the higher P codes we just accept the money and say 'Thank you very much.'"

When you bill for P codes they are a separate add-on charge to the surgical procedure's base value. As noted above physical status modifiers P1 and P2 do not merit additional reimbursement. But the physician can add one unit to the procedure's base units for a patient classified as P3 two units for a P4 patient and three units for a P5 patient.

For example the anesthesiologist may charge $50 per unit. If the physician provides anesthesia for treatment of an inguinal hernia (00830 Anesthesia for hernia repairs in lower abdomen; not otherwise specified) on a hypertensive patient the charge would be $250 (00830 is a four-unit procedure or $200; a hypertensive patient with no other health concerns would be classified P3 which adds one more unit to the procedure for a total charge of $250 for five units). The same procedure performed on a patient with severe heart disease would be charged at $350 (four units for the procedure and three units for the patient's P5 classification for a total of seven units at $50 each). The physician's time spent on the procedure would also be factored in for the total charge.

Document Multiple Diagnoses

  If the anesthesiologist is seeking additional reimbursement because of higher P codes the carrier may require three or four diagnoses to help justify the physical status classification. These can include primary diagnoses such as coronary artery disease (414.00 Coronary atherosclerosis of unspecified type of vessel native or graft) atrial fibrillation (427.31) and chronic obstructive pulmonary disease (496 Chronic airway obstruction not elsewhere classified). Conditions such as hypertension (401.9 Essential hypertension unspecified) and diabetes (various codes from group 250) may be used as supporting diagnoses.

For example Medicaid in California wants three or more diagnoses for patients classified as P3 or greater according to Barbara Johnson CPC MPC professional coder with Loma Linda University Anesthesiology Medical Group Inc. in Loma Linda Calif. But the diagnoses cannot all be related to the same problem she cautions such as coronary artery bypass graft (CABG) for coronary artery disease unstable angina mitral valve insufficiency and cardiomyopathy. But if the patient has several unrelated problems such as CABG with coronary artery disease renal insufficiency and hypertension the multiple-diagnosis criteria are met.

Some carriers and practitioners believe that if you're coding a P3 or above you should have an ICD-9 diagnosis code that can cause death. A patient with a diagnosis of inguinal hernia (550.9x Inguinal hernia without mention of obstruction or gangrene) and postnasal drip would raise eyebrows as a P3 patient. But if angina coronary artery disease or renal failure was added as a diagnosis code the physical status of P3 or greater might be understandable. A diagnosis of unstable angina or respiratory distress could explain a status of P4 and a P5 status might be justified by septic shock (785.59 Shock without mention of trauma other) or a ruptured abdominal aorta (441.3 Abdominal aneurysm ruptured).

When you are searching for additional diagnoses Johnson also suggests looking at the patient's medications. Notes regarding medications such as antihypertensive or thyroid supplements can help point to supporting diagnoses that carriers often require.

Distinguishing Between the Levels Can Be Tricky  

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. (All physicians would consider a blood pressure of 240/140 to be malignant hypertension qualifying her for P4 status but some might consider pressure of 150/92 as mild or P2 while others would classify it as P3.)

"Even though the criteria are set they don't come across the same " Johnson notes. "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."

"Similar patients with similar conditions (such as obesity mild hypertension or mild asthma) might be classed differently depending upon how much of an effect the doctor thinks the condition will have on anesthesia or surgery " Fuqua adds. "These are judgment calls by the doctors so there's always room for error. But I generally don't question a doctor's judgment. He examined the patient and knows the patient's extenuating circumstances and whether the patient's condition warrants the assignment of anything billable. We always default to a level P1 unless the doctor describes and documents it differently."