Mind your P modifiers or lose your reimbursement opportunities

Published: 08th June 2010
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Mind your P modifiers or lose your reimbursement opportunities

Be prepared with your documentation for reporting level P4 and higher.

Physical status modifiers, also called P modifiers, ASAs or ASA P codes, are a vital element of your anesthesia coding. If you do not use them properly, you could lose your reimbursement opportunities, or risk a payer audit.

Leave out P modifiers with Medicare, however check private payers

If your anesthesiologist works with a number of Medicare patients, you probably have not spent much time learning the finer points of anesthesia's physical status modifiers. Why? This is because Medicare does compensate for them.

You thought this was the end of the story? Not if your practice contracts with private payers. Many private payers will often pay for P modifiers if you follow the guidelines.

"Reporting is dependent on the carrier and can be dependent on whether the group negotiated for it in their agreement. Most government payers don't allow reporting or payment of PS modifiers,"according to Debbie Farmer, CPC, ACS-AN, coder with Auditing for Compliance & Education in Leawood, Kan.

For instance: According to a 2001 Aetna anesthesia policies memo, "When these modifiers/codes are reported, additional ASA units may be allowed and combined with the base unit value for the anesthesia service carried out. While the trick is in meeting those conditions, you do not have to shy away from P modifiers if you are well-versed with the basics.

Use six levels to define patient's status

The American Society of Anesthesiologist (ASA) developed physical status modifiers to allow medical coders to differentiate between different levels of complexity of anesthesia service. These levels are based on the patient's condition as follows:

  • P1 - Normal fit patient

  • P2 - Patient with slight systemic disease

  • P3 - Patient with moderate systemic disease which can be life threatening

  • P4 - Patient with severe systemic disease that's a constant threat to life

  • P5 - Moribund patient who is not expected to stay alive with or without the operation

  • P6 - Declared brain-dead patient whose organs are being removed for donor purposes.

    The ASA doesn't provide solid definitions for physical status modifiers as their use is based on clinical decisions the anesthesia provider makes for each patient.

    Hint: Most of your anesthesiologist's services call for a P1, P2, or P3 modifier. To utilize P$ or higher, you require clear documentation in the medical record to support its use. Even if your anesthesiologist categorizes a patient as P3, many payers will require more information to support the claim.

    How if functions: A patient with stable angina would be thought of as a P3 status. This patient has a systematic disease that could kill him, however he is stable and expected to fare well.

    A patient with a P4 status has his life continuously threatened by his disease. "ASA 4's are patients who aren't expected to die in the perioperative period, although it would not be totally unexpected if they do,"according to Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York. Someone with angina, or in congestive heart failure who needs surgery, would be a 4.

    See to it that you clarify Dx and documentation

    In its "Revised Hospital Anesthesia Services Interpretive Guidelines,"CMS offers clarification on minimum accepted standards of what should be incorporated in a pre-anesthesia evaluation of a patient, including "notation of anesthesia risk according to established standards of practice ( say for instance ASA classification of risk).

    Why it is important: The preop note must regularly include PS classification, says Groudine. If it does not, your practice may not be complying with CMS rules.

    The best bet to ensure you are using the right PS code is to check, and double-check, your physician's documentation. In many cases you can find the ASA classification included in the operating room nurse's notes.

    Heads up: Many times I see that a claim went in without a diagnosis to support the underlying condition for reporting the PS modifier and the carrier won't allow the additional unit,"says Farmer.

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