Modifier Coding Alert

Here’s why you must use modifiers even when you don’t get paid extra.

Whenever a provider administers anesthesia to a patient, you’ll want to include a physical status (“P”) modifier on the claim to show insurers the patient’s health status.

Reason: There is always the risk of adverse reaction when a patient needs anesthesia. The P modifiers shine a light on the patient’s physical status pre-anesthesia, which paints a better picture of the overall encounter.

Find out the inner workings of P modifiers with this crash course in representing the physical status of patients receiving anesthesia.

Show Potential Risk with P1-P6

Anesthesiologists use modifiers P1-P6 to indicate the overall health of the patient, as this is a factor in anesthesia administration.

According to Leslie Johnson, CPC, CSFAC, chief coding officer at PRN Advisors in Palm Coast, Fla.:

• Modifiers P1 (A normal healthy patient) and P2 (A patient with mild systemic disease) “indicate minimal to no risk to the patient during the surgery. Generally most people under the age of 30ish will fall into this category,” she says.
• Modifiers P3 (A patient with severe systemic disease) and P4 (A patient with severe systemic disease that is a constant threat to life) “indicate a moderate to constant threat to a patient’s life when undergoing surgery,” Johnson says.
• Modifier P5 (A moribund patient who is not expected to survive without the operation) is for patients that are “pretty sickly,” Johnson says. “The surgery could go one way, life, or another, death, but without the surgery, the patient will surely die.” 
• Modifier P6 (A declared brain-dead patient whose organs are being removed for donor purposes) “indicates a patient who is brain dead but the body is still alive,” explains Johnson. You’ll typically use P6 for a patient who is receiving anesthesia to harvest organs before the provider removes life support.

The lowdown: The use of anesthesia carries a lot of risk and can affect the patient’s outcome, explains Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO Certification Coaching Organization, LLC in Oceanville, N.J. P modifiers help paint a better picture of the encounter for the payer, as it clues the payer in to the patient’s overall health at the time of anesthesia.

Attach P Modifier Regardless of Payment

Though some payers — Medicare included — will not pay anything extra for the P modifiers, payers might require the modifiers to prove medical necessity for other anesthesia services in certain situations.

Also, some private payers might pay extra in certain P modifier situations, says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. If a payer calls for P modifiers, however, you should use them “whether it for allows additional payment or not,” Dennis says.

Keep Track of Payer Preferences on P Modifiers

Using the P modifiers gets more important with the higher numbers (P3-P6) because even though a payer might not reimburse extra for P1-P6, it could deny a claim for the anesthesia because the patient had an insufficient physical status level.

Example: Some payers that require P modifiers won’t pay for monitored anesthesia care (MAC) unless the patient has a P3 status or higher, Johnson says.

So let’s say the anesthesiologist performs 53 minutes of MAC on a patient undergoing a splenectomy due to a ruptured spleen. The patient has chronic coronary artery disease (CAD) and severe diabetes mellitus.

If the payer requires P modifiers for anesthesia claims, you would report G9363 (Duration of monitored anesthesia care [MAC] or peripheral nerve block [PNB] without the use of general anesthesia during an applicable procedure or general or neuraxial anesthesia less than 60 minutes, as documented in the anesthesia record) with either modifier P3 or P4 appended to indicate the patient’s health at the time of the anesthesia.

While you’ll want to use the P modifiers whenever the payer requires them, you’ll also want to make sure that you leave them off of claims for payers that don’t want them. Coders have reported getting denials for anesthesia services because they included a physical status modifier when the payer didn’t want it.

Bottom line: “It’s true that most private or commercial payers do recognize these [P] modifiers; but some don’t, so it’s important for anesthesia practices to keep track,” Johnson says.

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