Anesthesia Coding Alert

Question: Do you know if there is somewhere that gives a good description of what the different levels of physical status are? I’m trying to find something that would provide some guidance on how to classify the levels. I know the American Society of Anesthesiologists (ASA) has a description, like level 3 is for a patient with a severe systemic disease, but what would be considered severe systemic versus mild systemic? Any help would be appreciated!

New York Subscriber

Answer: The ASA offers a resource to help understand what types of conditions might fall under each of the physical status levels. The ASA Physical Status Classification System was updated in December 2020 and provides both adult and pediatric examples. You can find it at www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system.

The resource can help improve the accuracy of reporting the physical status modifiers P1 to P6. This tool is helpful for nonclinical coders, and it also helps with spot-checking your records to ensure documentation supports the physical status assigned. For instance, many coders pick up the physical status from the record and don’t get a copy of the preanesthesia assessment. But if the physician assigns a P3 (A patient with severe systemic disease) or P4 (A patient with severe systemic disease that is a constant threat to life), there should be comorbidities to support the codes in the preanesthesia assessment. Spot checks are an important compliance activity to make sure documentation supports the physical status assigned and that your anesthesia practice is coding accurately.