Appropriate Use of ASA Classification and Modifiers

Appropriate Use of ASA Classification and Modifiers

Upon completion of reading the following ASA memo, please fill out and submit a Certificate of Reading and Agreement to abide by the guidelines at the bottom of this page.

MEMO

TO:                  All CRNA’s and M.D.’s
FROM:             Louis Levin, M.D.
                        PMC, Compliance Medical Director
DATE:              June 7, 2011
RE:                   Appropriate Use of ASA Classification and Modifiers

There is misunderstanding in our practice and the anesthesia community nationwide about appropriate use of the ASA risk classification system and the use of the anesthesia modifiers.

We have researched these issues with the ASA and our billing companies in order to provide you with more clear-cut guidelines to improve the consistency and appropriate use of these concepts. 

ASA Physical Status

The ASA physical status classification system for assessing the fitness of patients before surgery In 1963 the American Society of Anesthesiologists (ASA) adopted the five-category physical status classification system; a sixth category was later added.  These are:

            1.  A normal healthy patient

            2.  A patient with mild systemic disease

            3.  A patient with severe systemic disease

            4.  A patient with severe systemic disease that is a constant threat to life.

            5.  A moribund patient who is not expected to survive without the operation.

            6.  A declared brain-dead patients whose organs are being removed for donor purposes.

The purpose of the grading system is simply to assess the degree of a patient’s "sickness" or "physical state" prior to selecting the anesthetic or prior to performing surgery. Describing patients’ preoperative physical status is used for recordkeeping, for communicating between colleagues, and to create a uniform system for statistical analysis. The grading system is not intended for use as a measure to predict operative risk.

If the surgery is an emergency, the physical status classification is followed by “E” (for emergency) for example “3E”.  Class 5 is usually an emergency and is therefore usually “5E”.  The class “6E” does not exist and is simply recorded as class “6”, as all organ retrieval in brain-dead patients is done urgently.  The original definition of emergency in 1940, when ASA classification was first designed, was “a surgical procedure which, in the surgeon’s opinion, should be performed without delay.”  [1] This gives an opportunity for a surgeon to manipulate the schedule of elective surgery cases for personal convenience.  An emergency is therefore now defined as existing when delay in treatment would significantly increase the threat to the patient’s life or body part.  [2] With this definition, severe pain due to broken bones, ureteric stone or parturition (giving birth) is not an emergency.

Different authors give different versions of this ASA definition, because this classification is vague and far from perfect.  Often different anesthesia providers assign different grades to the same patient.

The words systemic function limitation and others create confusion.  Some conditions and local disease are not “systemic diseases” (which means a generalized disorder of the whole body like diabetes or hypertension) which affect patient risk but are not mentioned in the ASA classification.  Similarly, the ASA system also does not mention cancer. 

Also, the ASA classification doesn’t describe the general health status of the patient when excluding the condition that indicates the surgery.  In fact, there are hospitals that do exclude the condition indicating the surgery.  This, in such hospitals, ASA1 may still refer to a patient in a severe medical emergency, such as for example a moribund patient due to a traumatic aortic rupture (which indicates the surgery) but otherwise being healthy. 

The compliance committee of PMC feels the Cleveland Clinic publication of the ASA Physical Classification System provide more in-depth descriptions of the system and should be used by all our practitioners.

In addition, we feel that there should be universal acceptance and use of the concept that many forms of cancer should be considered a systemic disease.  For example, a healthy patient with invasive breast cancer or colon cancer would be an ASA II.  In addition recent chemotherapy or radiation would be considered a system and/or a function limitation, so that those patients with cancer and either recent radiation or chemotherapy would be an ASA III.  This position is supported by our billing professionals at both Medac and ABC.

There will be differences between anesthesiologists on the classification of the same patient.  The MD completing the anesthesia pre-op is ultimately responsible for the decision based on his evaluation, and may have important implications.  For example, some of our outpatient facilities do not allow surgery on ASA4 patients to be performed. 

Obviously, there are financial implications as well although many payors  (Medicare  and Medicaid) do not pay more for ASA status.

We hope that this will provoke discussion and more consistent classification.

Field Avoidance and Position

The field avoidance and position change guidelines in the ASA Relative guide allow you to raise the base units to 5 base units for all those procedures that have a base of 3 -r 4 units and meet  fit 1 of 2 definitions/criteria;

1.  Field Avoidance - any procedure around the head, neck, and shoulder girdle requiring field avoidance has a minimum basic value of 5 base units, regardless of any lesser basic value assigned to such procedure.  FIELD AVOIDANCE BASICALLY MEANS THE ANESTHESIOLOGIST DOESN’T HAVE DIRECT ACCESS TO THE PATIENT’S AIRWAY DURING SURGERY, WHETHER IT IS DUE TO THE NATURE OF THE CASE ITSELF OR BECAUSE THE SURGEON HAS THE PATIENT IN A DIFFERENT POSITION THAN NORMAL, WHICH MAKES IT HIGHER RISH FOR THE ANESTHESIOLOGIST. 

Examples are eye cases, ENT-not PET, Shoulders or ACF’s.  Even breast reconstruction with arms tucked and Surgeons standing next to the patients heads can be coded as field avoidance. ACF’s and Breast Reconstruction have base units above 4 so being no reimbursement but should be noted on record for medical-legal reasons.

2.  Position Change -any procedure requiring a position other than supine or lithotomy has  a minimum basic value of 5 base units, regardless of any lesser basic value assigned to such procedure. 

 Although many payors do not pay for position change and field avoidance it is still important to properly use these modifiers with documentation on the anesthesia records and billing sheets.  Any missed revenue affects our ability to maintain compensation and service.

ASA Physical Classification System

The American Society of Anesthesiologists (ASA) Physical Status classification system was initially created in 1941 by the American Society of Anesthetists, an organization that later became the ASA.

The purpose of the grading system is simply to assess the degree of a patient’s "sickness" or "physical state" prior to selecting the anesthetic or prior to performing surgery. Describing patients’ preoperative physical status is used for recordkeeping, for communicating between colleagues, and to create a uniform system for statistical analysis. The grading system is not intended for use as a measure to predict operative risk.

The modern classification system consists of six categories, as described on the next page:

ASA Physical Status (PS) Classification System*:

ASA PS Category

Preoperative Health Status

Comments, Examples

*ASA PS classifications from the American Society of Anesthesiologists

ASA PS 1

Normal healthy patient

No organic, physiologic, or psychiatric disturbance; excludes the very young and very old; healthy with good exercise tolerance

 

ASA PS 2

Patients with mild systemic disease

No functional limitations; has a well-controlled disease of one body system; controlled hypertension or diabetes without systemic effects, cigarette smoking without chronic obstructive pulmonary disease (COPD); mild obesity, pregnancy

 

ASA PS 3

Patients with severe systemic disease

Some functional limitation; has a controlled disease of more than one body system or one major system; no immediate danger of death; controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure; bronchospastic disease with intermittent symptoms

 

ASA PS 4

Patients with severe systemic disease that is a constant threat to life

Has at least one severe disease that is poorly controlled or at end stage; possible risk of death; unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal failure

 

ASA PS 5

Moribund patients who are not expected to survive without the operation

Not expected to survive > 24 hours without surgery; imminent risk of death; multiorgan failure, sepsis syndrome with hemodynamic instability, hypothermia, poorly controlled coagulopathy

 

ASA PS 6

A declared brain-dead patient who organs are being removed for donor purposes

 

 

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 8/6/2010…#12976