By: Cindy Triplett, CPC, CANPC, CPMA
Senior Director, Anesthesia Education
When you administer anesthesia to a patient with a BMI over 40 or evaluate a patient who has chronic obstructive pulmonary disease, you may find yourself questioning what ASA status is most appropriate for that individual. In addition to the patient’s state of health on the day of anesthesia, the anesthetist must carefully consider and assess the patient’s comorbidities and then assign a physical status indicator.
Since reporting the patient’s physical status may impact payment, compliance implications exist for misreporting. For this reason, it is important to know how the system works and the documentation requirements. Read on for more details on each.
How the ASA Classification System Works
The American Society of Anesthesiologists (ASA) recognizes six physical status classifications (P1-P6) within 3 categories (adults, pediatrics, and obstetrics).
The ASA’s classification system is illustrated below. It guides the reader through the levels as they graduate in complexity, allowing the provider to select the one that best describes their patient at the time of service.
Statement on ASA Physical Status Classification System (asahq.org)
ASA PS Classification: ASA I
Definition: A normal healthy patient
| Adult Examples Including, but not limited to: | Pediatric Examples Including but not limited to: | Obstetric Examples Including but not limited to: |
|---|---|---|
| Healthy, non-smoking, no or minimal alcohol use. | Healthy (no acute or chronic disease), normal BMI percentile for age. | Not applicable. |
ASA PS Classification: ASA II
Definition: A patient with mild systemic disease
| Adult Examples Including, but not limited to: | Pediatric Examples Including but not limited to: | Obstetric Examples Including but not limited to: |
|---|---|---|
| Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease. | Asymptomatic congenital cardiac disease, well controlled dysrhythmias, asthma without exacerbation, well controlled epilepsy, non-insulin dependent diabetes mellitus, abnormal BMI percentile for age, mild/moderate OSA, oncologic state in remission, autism with mild limitations. | Normal pregnancy*, well controlled gestational HTN, controlled preeclampsia without severe features, diet-controlled gestational DM. |
ASA PS Classification: ASA III
Definition: A patient with severe systemic disease
| Adult Examples Including, but not limited to: | Pediatric Examples Including but not limited to: | Obstetric Examples Including but not limited to: |
|---|---|---|
| Substantive functional limitations; One or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents. | Uncorrected stable congenital cardiac abnormality, asthma with exacerbation, poorly controlled epilepsy, insulin dependent diabetes mellitus, morbid obesity, malnutrition, severe OSA, oncologic state, renal failure, muscular dystrophy, cystic fibrosis, history of organ transplantation, brain/spinal cord malformation, symptomatic hydrocephalus, premature infant PCA <60 weeks, autism with severe limitations, metabolic disease, difficult airway, long term parenteral nutrition. Full term infants <6 weeks of age. | Preeclampsia with severe features, gestational DM with complications or high insulin requirements, a thrombophilic disease requiring anticoagulation. |
ASA PS Classification: ASA IV
Definition: A patient with severe systemic disease that is a constant threat to life
| Adult Examples Including, but not limited to: | Pediatric Examples Including but not limited to: | Obstetric Examples Including but not limited to: |
|---|---|---|
| Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis. | Symptomatic congenital cardiac abnormality, congestive heart failure, active sequelae of prematurity, acute hypoxic-ischemic encephalopathy, shock, sepsis, disseminated intravascular coagulation, automatic implantable cardioverter-defibrillator, ventilator dependence, endocrinopathy, severe trauma, severe respiratory distress, advanced oncologic state. | Preeclampsia with severe features complicated by HELLP or other adverse event, peripartum cardiomyopathy with EF <40, uncorrected/decompensated heart disease, acquired or congenital. |
ASA PS Classification: ASA V
Definition: A moribund patient who is not expected to survive without the operation
| Adult Examples Including, but not limited to: | Pediatric Examples Including but not limited to: | Obstetric Examples Including but not limited to: |
|---|---|---|
| Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction. | Massive trauma, intracranial hemorrhage with mass effect, patient requiring ECMO, respiratory failure or arrest, malignant hypertension, decompensated congestive heart failure, hepatic encephalopathy, ischemic bowel, or multiple organ/system dysfunction. | Uterine rupture. |
ASA PS Classification: ASA VI
Definition: A declared brain-dead patient whose organs are being removed for donor purposes
Influential documentation… it’s in the detail
Patients with co-morbidities (such as frailty or being deconditioned) are subject to certain perioperative risks. When factoring them into the type of surgery, anesthesia providers have a better understanding of the overall risk stratification. To fully illustrate the complexity of the case, Ventra Health suggests utilizing pre-anesthesia assessment forms to capture the patient’s comorbidities and detail how they influence the case (see “monetary impact” below). For patients scoring ASA III and above, expound on which condition(s) justify this higher level.
Producing a payable claim
Understandably, some payers require diagnosis codes to support the ASA level selected by the provider. For the most streamlined approach to billing and to expedite payment, submit a copy of the pre-anesthesia assessment to your billing department or billing company. The assessment provides coders and billers with the information needed to complete their tasks promptly, and accurately, and reduces the number of queries back to the provider.
ASA classifications may have a monetary impact
For claim adjudication, the ASA classification is converted to a physical status modifier. The modifier begins with the letter “P” and is followed by a single digit from one (1) to six (6).
Base units have been appointed to levels three (III) through five (V), each having the potential for additional payment depending upon the payer’s policy. If the payer allows physical status compensation, the base units (as illustrated below) are added to the overall billing units, resulting in supplemental reimbursement.
| ASA PS Classification | Physical Status Modifier | Base Unit Value |
|---|---|---|
| ASA I | P1 | 0 |
| ASA II | P2 | 0 |
| ASA III | P3 | 1 |
| ASA IV | P4 | 2 |
| ASA V | P5 | 3 |
| ASA VI | P6 | 0 |
Customize examples for your practice
According to the ASA, Physical Status classification is a clinical decision based on multiple factors. The definitions and examples shown in the table above are nothing more than guidelines for the clinician. To improve communication and assessments for your organization, consider developing institutional-specific examples to supplement the ASA-approved examples.
What’s Next and How Ventra Health Can Help
Ventra Health has a team of anesthesia experts who can assist with documentation improvement. Please contact us for more information.
Ventra Health takes compliance very seriously. This is the final installment of our Provider Education team’s Compliance Blog Series, but stay tuned for more educational content in our upcoming blog series which will cover a range of topics around documentation, compliance, and quality reporting. In case you missed it, check out the full compliance series here.
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