Anesthesia Coding Alert

Question: What tips can you offer on distinguishing between CPT anesthesia physical status modifiers?

Pennsylvania Subscriber

Answer: The American Society of Anesthesiologists (ASA) doesn't fully define the physical status modifiers because their use is based on clinical decisions the anesthesia provider makes for each patient. Your provider assigns a physical status modifier during the preanesthesia assessment.

Some physicians are better at documenting conditions to support physical status than others, but keep these examples in mind as a way to gauge your own cases:

• P1 (A normal healthy patient) is generally a healthy patient who presents with minimal risks.

• P2 (A patient with mild systemic disease) applies to patients with conditions such as controlled diabetes.

• P3 (A patient with severe systemic disease) points to conditions such as severe diabetes with vascular complications.

• P4 (A patient with severe systemic disease that is a constant threat to life) and P5 (A moribund patient who is not expected to survive without the operation) both represent very high risk, sick patients or those in trauma situations.

Assigning physical status modifiers is very individualized and the information you find from one place to another might conflict. If you have questions, check with your anesthesiologist or nurse assistant for clarification.