July 22, 2019
In medicine, innovations are often developed for one purpose, but later become relevant to other applications. The same is true for ASA physical status. This clinical tool for classifying a patient’s preoperative surgical risk was adopted in the 1970s by the ASA, as a way of indicating the complexity of anesthesia and justifying additional payment by insurance. The “P” modifiers (as they came to be known) became a popular means of enhancing the anesthesia charge for complex cases, until Medicare eliminated them from their payment formula in the late 1970s. Since then, many other payers have followed suit, resulting in a perception within the anesthesia community that physical status modifiers are no longer relevant, except from a clinical documentation perspective. Actually, nothing could be further from the truth. In fact, we suggest that all our clients develop clear and consistent guidelines for their use. As we have come to learn: the devil is in the details.
The current ASA Physical Status Classification System originally included the following top-five categories. The sixth category was subsequently added.
- Healthy person
- Mild systemic disease
- Severe systemic disease
- Severe systemic disease that is a constant threat to life
- A moribund person who is not expected to survive without surgery
- A declared brain-dead person whose organs are being removed for donor purposes
Let us never underestimate the importance of the anesthesia coder, who must carefully review each part of the legal medical record to determine all appropriate billable elements, whether they may be reportable to a given patient’s insurance or not. Examples of these items include the date of service, the anesthesia provider’s name, the clinical service location, the final mode of anesthesia and the patient’s ASA status. It is a unique feature of ABC’s software, F1RSTAnesthesia (FA), that it both validates the coder’s input and filters out items based on the requirements of each insurance plan. FA also keeps information that may not be required for a particular claim as “TO,” tracking only, which can be invaluable in trending patterns of acuity by facility.
Insurance plans use the physical status modifiers for two main reasons. The first is to help support medical necessity for the anesthesia service, a fact that is becoming increasingly relevant for endoscopy cases. This has also been noted with “anesthesia for pain” procedures. These insurance plans can sometimes require physical status modifiers, even if they don’t pay for them separately. The second reason is “contractual carve outs.” If you check your managed care contracts, you will most likely find some which pay additional units per case for ASA III and above. Although reimbursement for this contractual provision makes up a very small percentage of practices’ revenue (less than 1%), it still helps the bottom line.
The chart below is a compilation of physical status data for a sample of 12 ABC clients which performed 58,000 anesthetics for GI cases in 2018. Based on this sample, 52% of all cases were classified as ASA I and II, which could potentially mean that this is the percentage of cases for which there is no payment for anesthesia, based on policy guidelines that have already been implemented by a number of large health plans. This is just one example of the value of reliable physical status data.
It is important that each member of your group have a common understanding of the physical status modifiers and their application. This is best accomplished by adding as an agenda item to one of your upcoming departmental meetings. After discussing the more common clinical scenarios, a consensus can be reached, so that all group members are documenting consistently. To this end, the ASA has compiled recommendations on the ASA classification system, which we have hyperlinked below for your reference:
*ASA clinical examples were added as a result of the October 2014 House of Delegates meeting.
In medicine, we never really know the value of specific aspects of clinical documentation until it becomes evident. What we are seeing in regard to physical status modifiers is a case in point. Once a given data element is included in the clinical record, it is essential that its documentation be consistent and appropriate. If you want more information about your use of physical status modifiers and the various ways they may be applied, please contact your account executive who will be happy to perform an assessment for you.