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Coding and Documentation Quick Tips from Holley

Let’s Talk About Physical Status

Per the American Society of Anesthesiologists- “Assigning a Physical Status classification level is a clinical decision based on multiple factors. While the Physical Status classification may initially be determined at various times during the preoperative assessment of the patient, the final assignment of Physical Status classification is made on the day of anesthesia care by the anesthesiologist after evaluating the patient.”

One roadblock frequently encountered is lack of DETAILED documentation in the record to support P3 and up physical status.  Payers are cracking down on paying these additional units if not correctly documented, in fact the payer will deny the entire claim if the Physical Status is not supported. 

Examples of inadequate documentation are listed below.

Diabetes type 2 not specified as controlled or uncontrolled.  Only uncontrolled Diabetes is eligible for P3 status.

Hypertension – not specified as controlled or uncontrolled.  Only uncontrolled Hypertension is eligible

Obesity/Obese – Obesity is only a P3 when it is documented as MORBID obesity with a BMI of 40+ This must be documented in the Anesthesia ROS/MEDHX

Coronary Artery Disease CAD- if the patient has a STENT this is automatic P3 but the stent must be documented by the anesthesia provider

ESRD-P3 is only applicable if the patient is NOT undergoing regularly scheduled dialysis

These are just a few examples, please review to the ASA Approved Examples for further details and documentation guidelines.

“The question you must ask yourself is “Could this procedure be performed under MAC alone?”” 

What is REALLY the Mode of Anesthesia?

Monitored anesthesia care, General, Regional, which type of anesthesia are you providing? When MAC and regional anesthesia are used together to provide anesthesia to a patient, many providers document the type of anesthesia as MAC.  Or MAC and regional.  This is often incorrect and leads to claims being coded incorrectly and denied.  The question you must ask yourself is “Could this procedure be performed under MAC alone?” If the answer is NO, the correct mode of anesthesia is REGIONAL and should be listed as such under the mode of anesthesia.  Often providers administer a little bit of MAC anesthesia for the patient to relax and be more comfortable for the procedure when a block is also being performed.  If this is the case, and the procedure CAN NOT be performed without the block, the documentation for the mode of anesthesia is REGIONAL, not MAC.  The documentation of the mode of anesthesia is extremely important and can cause claim denials especially when a post operative pain block is performed, and the record also states monitored anesthesia care. 


  • Anesthesia Start and Stop Time: Please use one method for tracking your time, whether it be by your cell phone, watch, smart watch,   If you are running multiple rooms, it is NOT the best idea to use the hospital provided clocks, as each clock may be off by one to two minutes.  Even one to two minutes can create concurrency errors. 
  • Mode of Anesthesia: The mode of anesthesia should be the same throughout the record and on any procedure notes. If the mode of anesthesia changes during the case, this must be documented in the anesthetic record, along with the reason for the change. Example: Spinal anesthesia for a cesarean section turns general anesthesia.  Please document the reason the mode changed.
  • Procedure and Diagnosis: It is extremely important that the anesthesia record has the procedure performed and the pre and post op diagnosis listed. This is to support the claim that goes to the insurance company, and because we code directly from the anesthesia record.
  • TEE Procedures: If a TEE procedure is performed, it is imperative that the diagnosis for the TEE be in the anesthesia record. For example, I25.110 is a supported diagnosis for an open-heart procedure, but it does not support the need for the TEE probe placement or the combination TEE Probe placement and exam.  It is also imperative that you clearly define if you are only placing the TEE probe (93313) or if you are placing and performing the exam (93312).

Holley Waters

Coding Manager
(706) 737-9250

PMI is very excited to partner with ASB and ASW and look forward to working closely with the providers and support staff.

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