Anesthesia’s Assessment of Physical Status
Summary: Assigning and supporting the patient's ASA status should not be approached in a haphazard or ho-hum manner, as its implications are far-reaching.
The world of tomorrow, as envisioned by futurists, such as Ray Kurzweil, Elon Musk and others, may very well witness an evolutionary shift where artificial intelligence and advanced robotics inexorably lead to significant changes in the essence of humanity. Some foresee a symbiosis between man and machine, where the human consciousness is uploaded into an indestructible robotic shell, fulfilling the age-old quest for immortality.
But until that day comes, there are still flesh-and-blood bodies that must be evaluated and treated by healthcare professionals. For anesthesiologists, that begins with the pre-anesthesia assessment (PAA). Diagnoses and co-morbidities are noted and documented, and then the patient is assigned a numeric-driven physical status indicator that is ultimately added to the anesthesia record.
Our readers are certainly familiar with the one-through-six physical status ranking system (with six representing brain-dead patients). However, as this system must be utilized on every anesthesia case, it may prove beneficial to explore its background, definitions and implications in a bit more detail.
Concept Inception
The "Physical Status Classification System" was developed by the American Society of Anesthesiologists (ASA), which is why we sometimes refer to the patient's "ASA status." The system has been in use for over 60 years and continues to evolve. The ASA developed the system as a means to assess and communicate a patient's pre-anesthesia medical co-morbidities. According to the ASA, "The classification system alone does not predict the perioperative risks, but used with other factors (e.g., type of surgery, frailty, level of deconditioning), it can be helpful in predicting perioperative risks."
Identifying a physical status level relative to a particular patient will entail clinical decision-making on the part of the provider and is based on multiple factors. It is the ASA's position that, while the physical status classification may initially be determined at various times during the preoperative assessment of the patient, the final assignment of a patient's physical status should be made on the day of anesthesia care by the anesthesia provider after evaluating the patient.
The Classification Levels
As previously indicated, the ASA physical status classification system has six levels potentially applicable to patients undergoing anesthesia care. But how does one determine the level that is best suited for the patient currently presenting? Fortunately, the ASA's Committee on Economics has developed a table, complete with clinical examples, that will assist the provider in determining the physical status level that is most appropriate for each patient. Over the years, the Committee on Economics has updated their physical status guidance, with the most recent having been amended in December of 2020.
At this point, it may be helpful to provide the most current ASA physical status classification table. According to the ASA, "To improve communication and assessments at a specific institution, anesthesiology departments may choose to develop institutional-specific examples to supplement the ASA-approved examples." With this in mind, we recommend that you review the ASA table, as provided below.
Current Definitions and ASA-Approved Examples
* Although pregnancy is not a disease, the parturient's physiologic state is significantly altered from when the woman is not pregnant, hence the assignment of ASA 2 for a woman with uncomplicated pregnancy
**The addition of "E" denotes Emergency surgery: (An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part)
Important Implications
Determining and documenting a physical status level are not only important from a clinical perspective; these tasks are mandated from a compliance perspective, as well. The Medicare Conditions of Participation (CoP) rules require a physical status level to be documented in the medical record. This is from the Interpretive Guidelines of the Medicare CoPs relative to anesthesia services:
Elements that must be reviewed and updated as necessary within 48 hours, but which may also have been performed during or within 30 days prior to the 48-hour time period, in preparation for the procedure: • Notation of anesthesia risk according to established standards of practice (e.g., ASA classification of risk).
Beyond the compliance requirement, the ASA level may be critical to establishing medical necessity and thus, ultimately, payment, in certain cases. There are some commercial and Medicare medical policies that condition provider reimbursement upon the patient's co-morbidities and/or physical status. For example, one medical policy in recent years indicated that payment may not be forthcoming unless the patient had a documented physical status of three or higher. Referring to the above chart, it becomes clear that assigning a level three ASA classification can be accomplished by simply documenting a patient's body mass index (BMI) of 40 or more, for example. Though it is painful to admit it, making such a determination in the context of today's fast-food populace may not be that difficult—at least as it concerns a good percentage of those who present to the anesthesia provider. The greater point is that using the above table and its real-world examples can assist the provider in making more accurate determinations of the patient's true physical status.
Keeping in mind the clinical, legal and financial implications of the physical status component of the medical record, anesthesia providers would do well to (a) thoroughly review the ASA's helpful classification table provided above, and (b) use extra care in obtaining and documenting their patients' true physical status. For more information on this or other topics, please contact your account executive, or reach out to us at info@anesthesiallc.com.