ASA Classification Clarification

[Sublimazing]

Sorry to intrude on your forum...but I had a somewhat trivial question that wasnt particularly addressed in Basics, Secrets, Lange, or anything else I have on my shelf

One of my attendings has me classify all Non-ambulatory patients as ASA 3 based solely off of METS, saying unless they are doing some "serious rowing" that they had to have a low mets score

I couldnt find this documented anywhere...but it doesnt necessarily seem incorrect? We do a lot of special needs GA so it actually comes up like 3-5 times a week for me

Thoughts?

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[Idiopathic]

very subjective, you could make the case for almost anyone to be asa 3, if they have any condition that requires they take a medicine, alter lifestyle or see a physician regularly, and you wouldnt necessarily be wrong, but other people might see it differently.

 

[pgg]

ASA 2s are people with mild or well-controlled systemic disease. I'd lean toward calling someone who's non-ambulatory as neither mild nor well-controlled, so ASA 3 seems reasonable.

 

[cchoukal]

Residents are often surprised (after hearing various attendings spout their own interpretations of the ASA classes) how parsimonious the actual categories are:

ASA Physical Status 1 - A normal healthy patient
ASA Physical Status 2 - A patient with mild systemic disease
ASA Physical Status 3 - A patient with severe systemic disease
ASA Physical Status 4 - A patient with severe systemic disease that is a constant threat to life
ASA Physical Status 5 - A moribund patient who is not expected to survive without the operation
ASA Physical Status 6 - A declared brain-dead patient whose organs are being removed for donor purposes

These seem deliberately vague, and I think that allows a certain amount of artistic freedom in the assignment of status. The PP guys can tell you better than I can, but I believe there are modifiers for higher statuses so that higher billing amounts can be sought.

 

[BLADEMDA]

Residents are often surprised (after hearing various attendings spout their own interpretations of the ASA classes) how parsimonious the actual categories are:

ASA Physical Status 1 - A normal healthy patient
ASA Physical Status 2 - A patient with mild systemic disease
ASA Physical Status 3 - A patient with severe systemic disease
ASA Physical Status 4 - A patient with severe systemic disease that is a constant threat to life
ASA Physical Status 5 - A moribund patient who is not expected to survive without the operation
ASA Physical Status 6 - A declared brain-dead patient whose organs are being removed for donor purposes

These seem deliberately vague, and I think that allows a certain amount of artistic freedom in the assignment of status. The PP guys can tell you better than I can, but I believe there are modifiers for higher statuses so that higher billing amounts can be sought.

Once you have been at this gig for a while then it becomes clearer who is ASA 2 vs ASA 3 most of the time. Still, as one transitions from ASA 2 to ASA 3 the line is blurry.

For example, an ASA 2 patient with DM, HTN, etc. in 2011 becomes an ASA 3 in 2012 when he/she develops PVD and shows up for a procedure on that extremity to restore blood flow.

The ASA classfication is indeed "vague" and allows individual practitioners room to vary in ratings. One provider may call a person an ASA 2 while another would classify that same person as an ASA 3. I'd rather err of the higher classification if several medical conditions are present and the patient is non ambulatory (can't walk).

I think the classification from ASA 3 to ASA 4 is even more variable from provider to provider with a tendency to underclassify these sicker patients.

 

[DrN2O]

People argue whether ESRD on dialysis is a 4--constant threat to life without a machine.
Someone also claim every heart patient he does is a 4.
I tend to agree with the first, but not the second.

 

[RxBoy]

When is someone an ASA 5 but not E?

 

[MTGas2B]

When is someone an ASA 5 but not E?

When they're fasted


On the iPhone

 

[fakin' the funk]

When is someone an ASA 5 but not E?

I was playing this game the other day with one of my co-residents. I couldn't come up with a great example. Maybe, case the patient isn't expected to survive without needs some equipment or personnel which are remote and the case is pushed back 4-6 hours?

Similarly, when is an ASA6 an ASA6E? I've never heard of an "emergent" procurement, usually if the donor is circling the drain hemodynamically they try to tune them up in the ICU first or just abort.

 

[urge]

Sorry to intrude on your forum...but I had a somewhat trivial question that wasnt particularly addressed in Basics, Secrets, Lange, or anything else I have on my shelf

One of my attendings has me classify all Non-ambulatory patients as ASA 3 based solely off of METS, saying unless they are doing some "serious rowing" that they had to have a low mets score

I couldnt find this documented anywhere...but it doesnt necessarily seem incorrect? We do a lot of special needs GA so it actually comes up like 3-5 times a week for me

Thoughts?

Why are they not walking? DM, PVD, traumatic amputation, bad back?

If they have 2 legs and not waking I would agree with your attending.

 

[BobBarker]

I was playing this game the other day with one of my co-residents. I couldn't come up with a great example. Maybe, case the patient isn't expected to survive without needs some equipment or personnel which are remote and the case is pushed back 4-6 hours?

Similarly, when is an ASA6 an ASA6E? I've never heard of an "emergent" procurement, usually if the donor is circling the drain hemodynamically they try to tune them up in the ICU first or just abort.

Why abort? What is there to lose by just taking the already dead person to the OR?

 

[lushmd]

Why abort? What is there to lose by just taking the already dead person to the OR?

Because there's little utility in harvesting crap organs.

 

[Ignatius J]

I was playing this game the other day with one of my co-residents. I couldn't come up with a great example. Maybe, case the patient isn't expected to survive without needs some equipment or personnel which are remote and the case is pushed back 4-6 hours?

Similarly, when is an ASA6 an ASA6E? I've never heard of an "emergent" procurement, usually if the donor is circling the drain hemodynamically they try to tune them up in the ICU first or just abort.

To answer the first question, perhaps someone is ASA 5 when they are having a malignant tumor resection ie I think you could make an argument for pelvic exenerations, radical mastectomies, craniotomies for GBMs are ASA 5s without the E attached. It's all subjective, but that's what I use.

 

[WholeLottaGame7]

People argue whether ESRD on dialysis is a 4--constant threat to life without a machine.
Someone also claim every heart patient he does is a 4.
I tend to agree with the first, but not the second.

I know there have been threads on the dialysis question; I fall on the ASA4 side of that debate. I've never thought of heart cases that way but the more I think about it, the more I wouldn't necessarily disagree. If you have a >70% stenosis of one of your coronaries, I can buy that as being a constant threat to life.

I'd have to agree with Blade, it seems like even if we may overcall ASA3s, we probably undercall ASA4s.

 

[BobBarker]

Is there a billing difference from 3s to 4s to 5s? I have been told that 1s and 2s are the same in the past. Any difference for E's?

 

[lushmd]

Is there a billing difference from 3s to 4s to 5s? I have been told that 1s and 2s are the same in the past. Any difference for E's?

From what I'm told, it depends on the insurance company.

 

[RxBoy]

To answer the first question, perhaps someone is ASA 5 when they are having a malignant tumor resection ie I think you could make an argument for pelvic exenerations, radical mastectomies, craniotomies for GBMs are ASA 5s without the E attached. It's all subjective, but that's what I use.

Huh? THose are all ASA 4's

ASA 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.

http://my.clevelandclinic.org/services/anesthesia/hic_asa_physical_classification_system.aspx


Last ASA 5 (5E) I did was about 3 months ago. Dude was a mess, POD7 aorto bifem repair, in septic shock, DIC, fresh trach sent to the OR for a massive retro-peritoneal evacuation. Coded in transport back to ICU. That's an ASA 5.

If a pt can walk through the front doors, they're not a 5. Simple as that.

 

[fakin' the funk]

Huh? THose are all ASA 4's

ASA 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.

http://my.clevelandclinic.org/services/anesthesia/hic_asa_physical_classification_system.aspx


Last ASA 5 (5E) I did was about 3 months ago. Dude was a mess, POD7 aorto bifem repair, in septic shock, DIC, fresh trach sent to the OR for a massive retro-peritoneal evacuation. Coded in transport back to ICU. That's an ASA 5.

If a pt can walk through the front doors, they're not a 5. Simple as that.

Thank you for yet again quoting a Cleveland Clinic publication. But that is one interpretation...which is the upshot of what everyone else here has been saying. The ASA says just what is in bold.

 

[jwk]

Is there a billing difference from 3s to 4s to 5s? I have been told that 1s and 2s are the same in the past. Any difference for E's?

ASA 1 and 2 = 0 RVU
ASA 3 = 1 RVU
ASA 4 = 2 RVU
ASA 5 = 4 RVU
ASA 6 = 0 RVU

Adding the E is 1 or 2 units.

Some insurance companies have their own values attached, and as I recall, Medicare doesn't follow this either.

 

[BobBarker]

What about calling every labor epidural a 2E? I have seen an attending do this before.

 

[Impromptu]

There are the various of gunshot, automobile, and motorcycle traumas who will become progressively unstable in the emergency room because of ongoing bleeding whom I will make a 5E, though they may have walked in, or were at least talking and interactive from the stretcher.

 

[IlDestriero]

One could walk into the ED with necrotizing fasciitis. I've seen it in walk-ins twice. They came in as they started to circle the drain and go septic. That's a 5e.

 

[IlDestriero]

What about calling every labor epidural a 2E? I have seen an attending do this before.

Ridiculous. Sounds like fraud to me. There's nothing emergent about a routine epidural.

 

[jwk]

Ridiculous. Sounds like fraud to me. There's nothing emergent about a routine epidural.

Do you wait 8 hours for NPO before placing the epidural?

What about the scheduled repeat section than comes in in labor a week early and needs a section? E or no-E ?

 

[Ignatius J]

Huh? THose are all ASA 4's

ASA 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.

http://my.clevelandclinic.org/services/anesthesia/hic_asa_physical_classification_system.aspx


Last ASA 5 (5E) I did was about 3 months ago. Dude was a mess, POD7 aorto bifem repair, in septic shock, DIC, fresh trach sent to the OR for a massive retro-peritoneal evacuation. Coded in transport back to ICU. That's an ASA 5.

If a pt can walk through the front doors, they're not a 5. Simple as that.

Again, that's your own interpretation. By an strict interpretation of the wording, you can argue that a patient with a malignant cancer who will die without the operation is an ASA 5. You totally just arbitrarily picked 24 hours as the cutoff.

 

[IlDestriero]

Do you wait 8 hours for NPO before placing the epidural?

What about the scheduled repeat section than comes in in labor a week early and needs a section? E or no-E ?

No.
Yes. But that's not a routine epidural, which Bobs attending would call E.

 

[Mman]

Do you wait 8 hours for NPO before placing the epidural?

What about the scheduled repeat section than comes in in labor a week early and needs a section? E or no-E ?

An epidural isn't an anesthetic. That's why you aren't waiting for them to be NPO. It has nothing to do with the E modifier on the ASA status. When they later come for a c-section for NRFHT, then it's an E.

And any woman in labor for a repeat is an E. If you wait too long they are at risk for uterine rupture, so that's kind of an emergency.

 

[Ignatius J]

An epidural isn't an anesthetic. That's why you aren't waiting for them to be NPO. It has nothing to do with the E modifier on the ASA status. When they later come for a c-section for NRFHT, then it's an E.

And any woman in labor for a repeat is an E. If you wait too long they are at risk for uterine rupture, so that's kind of an emergency.

I agree that an epidural isn't an 'E', but it is absolutely, unequivocally, an anesthetic.

 

[Mman]

I agree that an epidural isn't an 'E', but it is absolutely, unequivocally, an anesthetic.

Federal regulations disagree with you. It's a pain procedure. It has the potential to evolve into an anesthetic, but for billing purposes it isn't an anesthetic.

 

[lushmd]

Federal regulations disagree with you. It's a pain procedure. It has the potential to evolve into an anesthetic, but for billing purposes it isn't an anesthetic.

I'll have to look into this further, but from what I recall, a labor epidural is distinct from an epidural steroid injection in that one can also bill for the time involved in managing it (i.e. redose, hypotension, etc...).

 

[ssmallz]

I would call a labor epidural a 2E for the following reasons

1) Would you place an epdural in a pt who just ate a cheeseburger? Of course you would, even the most conservative academic OB attending would because the pt needs the epidural for pain relief and by the time 8 hours pass she could be delivered. Contrast that to a non emergent c-section where the conservative doc waits 8hrs. I know this isn't a popular view among the pp dudes out there, myself included, but it's certainly a reasonable assertion.

2) Have you ever been called to do an epidural @ 3am? Of course you have, and IMO any case being done @ 3am is an emergency because if it could wait, we'd all do them at 7am

The better question is why people don't classify this as emergent. It's not much different than a lap appy IMO, they both need to go asap

 

[Mman]

I would call a labor epidural a 2E for the following reasons

1) Would you place an epdural in a pt who just ate a cheeseburger? Of course you would, even the most conservative academic OB attending would because the pt needs the epidural for pain relief and by the time 8 hours pass she could be delivered. Contrast that to a non emergent c-section where the conservative doc waits 8hrs. I know this isn't a popular view among the pp dudes out there, myself included, but it's certainly a reasonable assertion.

2) Have you ever been called to do an epidural @ 3am? Of course you have, and IMO any case being done @ 3am is an emergency because if it could wait, we'd all do them at 7am

The better question is why people don't classify this as emergent. It's not much different than a lap appy IMO, they both need to go asap

ASA physical status. Labor epidural not an anesthetic. Pain is not an emergency. It's not an appendectomy where everyone would agree the appendix needs to come out urgently. It's a pain procedure that many women choose not to have. It's completely elective. We do it at all hours because we are nice and that's what the patient wants.

Have I ever been called to do an epidural @ 3 AM? Of course. And it's not a "case being done at 3AM". It's a procedure that could be done at any point in time or not done at all. You are choosing to do it when the patient requests it.

 

[IlDestriero]

ASA physical status. Labor epidural not an anesthetic. Pain is not an emergency. It's not an appendectomy where everyone would agree the appendix needs to come out urgently. It's a pain procedure that many women choose not to have. It's completely elective. We do it at all hours because we are nice and that's what the patient wants.

Have I ever been called to do an epidural @ 3 AM? Of course. And it's not a "case being done at 3AM". It's a procedure that could be done at any point in time or not done at all. You are choosing to do it when the patient requests it.

Absolutely right. An epidural is elective by definition for almost all women in labor. Not having one in all but the most high risk patients is probably a bad idea, but it's still elective. Even a 2am epidural. If it was delayed because you were tied up with another c-section, helping with a crashing trauma/icu patient in the OR, in a fender bender on the way in, etc. nothing would happen. Except for a PO'ed mama.
When the c-section is called it still might not be an E. Great strip with failure to progress, a failed induction, we've all sat on those patients for hours to watch a shady strip for a while or do an actual urgent section.

 

[Ignatius J]

Federal regulations disagree with you. It's a pain procedure. It has the potential to evolve into an anesthetic, but for billing purposes it isn't an anesthetic.

Do you have the source on that?

As far as I know, at my institution it is billed as a 'regional anesthetic'.

 

[Mman]

Do you have the source on that?

As far as I know, at my institution it is billed as a 'regional anesthetic'.

CMS defines it as a procedure. That's why I can go perform one while having 4 ORs running. It isn't considered a separate anesthetic that you are billing for. A private insurer can pay for it however they want, but as far as CMS conditions of participation for a hospital it is the same as going to do an emergency intubation on the floor.