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In the field of anesthesia billing, physical status modifiers are important reflections of patients’ clinical conditions and the associated risk of administering anesthesia. Accurate usage of physical status modifiers is crucial to maintaining an ethical medical practice and financial integrity.
Modifiers range from P1 (a normal healthy patient), P2 (a patient with mild systemic disease), P3 (a patient with severe systemic disease), P4 (a patient with severe systemic disease that is a constant threat to life), P5 (a moribund patient who is not expected to survive without the operation) to P6 (a declared brain-dead patient whose organs are being removed for donor purposes). Physical status modifiers serve not only as an indicator of a patient’s preoperative health status but also as a critical determinant in the calculation of anesthesia providers’ fees in the context of medical billing. The patient modifier can be further translated to the corresponding ASA Physical Status Classification, ranging from ASA-I (no history of smoking, drinking, or major disease), ASA-II (mild diseases without major limitations), ASA-III (moderate to severe disease with major limitations), ASA-IV (life-saving intervention needed, for example, dialysis) to ASA-V (severe progressed condition that is life-threatening, such as a ruptured abdominal/thoracic aneurysm, massive trauma or intracranial bleed). Misunderstandings of how both categories are used and notated leads to inaccurate documentation of the health status of patients, which can lead to incorrect billing claims. Misclassification invites audits and financial losses to both the patient and the healthcare institution.2,1
It’s crucial to understand that misapplying physical status modifiers in either clinical practice or anesthesia billing can have severe consequences. Anesthesia providers who do so, whether due to a lack of education or negligence, may unknowingly subject patients to inappropriate levels of anesthesia risk without proper justification or reimbursement. For example, if a patient with severe systemic disease (classified under P3 or ASA-PSIII) is mistakenly documented as having mild systemic disease (P2 or ASA-PSII), the anesthesia provider may not receive appropriate reimbursement reflective of the higher level of care provided. Patient safety is impacted by the failure to communicate essential health status information accurately, with influence on perioperative management strategies. Such clinical errors can undermine the quality of care provided to those who are living with severe systemic diseases.1,3
There is a misconception that ASA physical status modifiers lost their relevance when Medicare eliminated separate payments for them in the late 1970s. Despite Medicare’s stance on their “informational only” status, these modifiers continue to play a crucial role in validating medical necessity and managing reimbursements within private insurance frameworks. Private insurance plans rely on these modifiers to validate medical necessity and manage contractual carve-outs where additional units are being reimbursed for cases classified as PIII and above. A survey conducted among 12 anesthesia practices revealed that 52% of their GI anesthetic cases were categorized as ASAI or ASAII, with a ranking of “healthy, non-smoker and non-drinker” and “mild disease with no substantial impairment, for example, smoker, obesity and pregnancy” respectively. These scores would result in a lack of reimbursement for those services based on existing policy guidelines held by private insurers. 2,3 Recent moves by certain private insurances to eliminate physical status modifiers from anesthesia billing have received strong pushback from providers.
To ensure ethical billing practices and safeguard patient well-being, it’s essential for healthcare organizations to establish standardized protocols and continuous educational initiatives that focus on the accurate application and documentation of physical status modifiers. By doing so, healthcare organizations will prevent financial losses due to incorrect billing claims but also uphold the highest standards of medical ethics and patient care. 4
References
1. Merrick, Sharon K. “Physical Status and Qualifying Circumstances.” ASA Monitor, vol. 85, no. 12, Dec. 2021, p. 38, doi:10.1097/01.asm.0000803364.48940.0e.
2. Leahy, Izabela, et al. “Does the Current American Society of Anesthesiologists Physical Status Classification Represent the Chronic Disease Burden in Children Undergoing General Anesthesia?” Anesthesia and Analgesia/Anesthesia & Analgesia, vol. 129, no. 4, Oct. 2019, pp. 1175–80, doi:10.1213/ane.0000000000003911.
3. Charles, Emily. Do ASA Physical Status Modifiers Still Matter in Anesthesia Billing? | Anesthesia Business Consultants. www.anesthesiallc.com/publications/anesthesia-provider-news-ealerts/1237-do-asa-physical-status-modifiers-still-matter-in-anesthesia-billing-2.
4. “Anesthesia Payment Basics Series: #4 Physical Status.” American Society of Anesthesiologists (ASA), www.asahq.org/quality-and-practice-management/managing-your-practice/timely-topics-in-payment-and-practice-management/anesthesia-payment-basics-series-4-physical-status#.
