Revenue Cycle Insider

Some payers consider physical status just information, but they contextualize some anesthesia services.

Coding and billing for anesthesia services can quickly turn into a complicated task. Without the proper documentation, use of payer guidelines, and appropriate clinical documentation, you can easily head down a road of noncompliance.

Let’s delve into the underbelly of anesthesia physical status modifiers, payer guidelines, documentation examples, and common mistakes that could lead to audit scrutiny and even risk of noncompliance.

Know Your Physical Status Modifiers

Coding and billing of anesthesia services begins with physical status modifiers. It is important to understand how to utilize and assign them appropriately to ensure proper claim payments.

Physical status modifiers are utilized to report the overall physical condition (health) of the patient at the time of a procedure and can have a positive, or sometimes negative, effect on the profitability of such services.

Let’s define each physical status modifier and look at some examples below:

• P1 (Normal healthy patient)
• P1 documentation example: A normal, healthy 24-year-old presents for elective right shoulder arthroscopy. Systemic review reveals no history of cardiac, pulmonary, renal, or endocrine disease. Review of Social History indicates patient has no history of smoking and/or social alcohol use. Patient also reveals no drug allergies. Review of Airway/Vital Signs: Patient is noted to have Mallamptai Class I airway, a blood pressure of 114/76, and normal heart rate of 73 beats per minute.
• P2 (Patient with mild systemic disease)
• P2 documentation example: 55-year-old female with well-controlled hypertension. Systemic review reveals patient with one of the following conditions: well-controlled hypertension, controlled diabetes mellitus without systemic complications, or mild obesity with body mass index between 35-40. Review of Social History indicates patient uses alcohol socially or reveals active and/or history of smoking. Review of Airway/Vital Signs patient is noted to have Mallamptai Class II airway, a blood pressure of 111/82, and normal heart rate of 82 beats per minute. Patient is also noted to have well-controlled type II diabetes mellitus without any underlying complications, which is diet controlled.
• P3 (Patient with severe systemic disease)
• P3 documentation example: 75-year-old male scheduled for a right knee replacement. Systemic review reveals patient with one of the following conditions: chronic obstructive pulmonary disease (COPD) requiring home oxygen, also affecting patient’s activities of daily living, poorly controlled type II diabetes, patient on insulin therapy, uncontrolled hypertension with renal insufficiency, or morbid obesity with BMI >40. Review of Social History indicates patient is a heavy cigarette smoker and uses alcohol daily. Review of Airway/Vital Signs: Patient is noted to have Mallampati class III airway, blood pressure of 160/93, and a heart rate of 93 beats per minute. Patient is also noted to have hyperglycemia on arrival (153 per fingerstick).
• P4 (Patient with severe systemic disease (constant threat to life))
• P4 documentation example: 85-year-old patient presents for triple coronary artery bypass grafting following acute myocardial infarction. Systemic review reveals a patient with ongoing demand ischemia and reduced ejection fraction, uncontrolled hypertension now in crisis, and uncontrolled type II diabetes, non-compliant with insulin regimen. Review of Social History indicates patient with history of significant alcohol abuse who continues to smoke cigarettes, even after multiple attempts for cessation counseling. Review of Airway/Vital Signs: Patient is noted to have Mallampati class IV along with esophageal lesions and spasm, blood pressure is 210/115, and heart rate is continuously over 140 beats per minute. Patient is also noted to have end-stage renal disease and is dialysis dependent.
• P5 (Moribund patient who is not expected to survive without the operation)
• P5 documentation example: 35-year-old male involved in a roll-over motor vehicle accident. Patient suffered massive head trauma and now has intracranial bleeding.
• P6 (Declared brain-dead patient whose organs are being removed for donor purposes)

Report Qualifying Circumstances

There are numerous qualifying circumstances that you should report separately if services are deemed reasonable and necessary. The additional code value is significant and could possibly mean a higher calculated payment for the respective anesthesiologist and certified registered nurse anesthetist (CRNA) alike. 

Reimbursement for +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70) adds an additional 1 unit of anesthesia when documented and captured appropriately. If one fails to submit +99100, the provider may not receive full reimbursement. Reporting qualifying circumstances can also lead to better clinical documentation practices and improved compliance.

Reimbursement for +99140 (Anesthesia complicated by emergency conditions) depends on documentation within the medical record and requires assignment of the “emergency” along with the submission of this code.

For example: A 65-year-old male falls from a ladder while cutting limbs from a tree. The patient sustains a massive joint injury to their left knee and bleeds uncontrollably. The emergency department (ED) physician consults with orthopedics and decides it is necessary for the patient to undergo an emergency surgical procedure to place the joint back into place and control the bleeding.

Understand the Context Surrounding Physical Status Modifiers

For over 30 years, anesthesiologists have utilized physical status modifiers to classify patients into categories according to comorbidities. These modifiers, although not reimbursed through most insurance companies, relay how moderate to severe comorbidities increase the intensity of work of anesthesia versus those of a healthy patient when receiving the same anesthetic. The addition or deletion of the code or modifier from claims data could have a positive or negative profitability outcome for your group/facility. One of the most common trends is finding physical status modifiers absent from claims because “they are not reimbursed.”

The Centers for Medicare & Medicaid Services (CMS) considers physical status modifiers “strictly informational” and does not allow for additional reimbursement. However, even though such a modifier is informational, the patient’s physical status undergoing anesthesia is still essential context, and the modifier should be assigned to the claim.an essential modifier such as a patient’s physical status undergoing anesthesia should be assigned to the claim. Other insurances such as Aetna, United Healthcare, and Blue Cross Blue Shield (in Texas, Oklahoma, Illinois, and New Mexico) all follow CMS’ policy of no reimbursement; however, no guideline states they should not be listed on the claim form.

Conversely, payers such as Anthem, Medica, select state and regional Blue Cross Blue Shield Plans, and many workers’ compensation entities will reimburse for physical status modifiers, especially P3 through P5.

You should remember that patients with underlying comorbidities utilize more resources, such as medications and extensive monitoring during both pre- and postoperative management. Payers rely on receipt of physical status modifiers on claims to track patients’ chronic conditions which, in turn, facilities utilize to classify resources.   

In summary, anesthesia coding is not just what drug, what time, what provider. Physical status modifiers provide more context, and using them correctly requires knowing and reporting additional components such as physical condition and underlying physical circumstances.

Amy Pritchett, MSHA, AAPC Fellow, RAP, CRC, CPA-RA, CCS, CPC-I, CPMA, CPCO, CDEI, CDEO,
CDEC, CANPC, CASCC, Dental Billing/Coding Expert, Director at Pinnacle Healthcare Consulting