Stephanie R. Goodman, MD
Assistant Professor of Anesthesiology
Department of Anesthesiology
College of Physicians & Surgeons of Columbia University
Women presenting for labor analgesia should NOT be classified using the ASA "E" designation. The reasons for opposing this suggestion are based on the historical and contemporary epidemiologic use of the ASA classification, the rational medical definition of an emergency, and the implications for billing.
In 1940, a committee of the American Society of Anesthetists suggested the concept of a physical status classification. This was originally designed for the "collection and tabulation of statistical data in anesthesia" and was specifically meant not to estimate operative risk.1The system became known as the ASA Classification of Physical Status and attempted to grade patients in relation to their physical state only. The relationship to the operative procedure, the ability of the surgeon or anesthesiologist, and the type of anesthesia were not part of the grading system.
The original classification contained 6 groups with the 5th and 6th groups as emergencies of the first 4 classes. This was later modified in 1962 to include the 5 groups, as we know them today.2 The original definition of emergency in 1940 was "a surgical procedure which, in the surgeon's opinion, should be performed without delay."1 In 1962, an "E" was placed after the 5 groups in the event of an emergency operation, but the definition of emergency was not refined.2
While labor analgesia is usually provided without delay, it is not a surgical procedure; it is an anesthetic procedure. This original definition in 1940 was not designed to apply to labor epidurals since at the time these were not performed. Furthermore, if the "surgeon's opinion" determines the emergency designation, then all cases could become emergencies so as not to "delay" the surgeon. I have yet to meet a surgeon who doesn't try to manipulate the schedule for his or her convenience.
Although the original creation of the Physical Status classification was not meant to estimate operative risk, it has been used for over six decades and been shown to correlate with surgical morbidity and mortality.3,4,5 Multiple studies have confirmed that when the ASA status contains an "E," the risk of complications from surgery and anesthesia increases.6,7,8 Thus, the ASA classification has been of value in epidemiologic and statistical studies of operative and anesthetic morbidity and mortality. There is no rationale for using the "E" designation for labor epidurals since essentially they would ALL be "E." In contrast, it is helpful to designate cesarean sections as "E" versus "non-E" when done emergently or electively since then outcome differences can be evaluated.
Currently, the ASA Physical Status classification system is used routinely for billing purposes. Already by 1978, 43% of respondents to a postal questionnaire were using it for billing.9 According to the 2002 American Society of Anesthesiologists Relative Value Guide, anesthesia complicated by emergency conditions can be coded as "E."10 Labor epidurals or spinals are not "complicated" by the presence of labor, they are necessitated (or at least requested) by its presence. 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."10 Although obstetric anesthesiologists frequently argue, with cause, that the presence of an epidural in a high risk parturient may decrease morbidity, it is exceptionally rare that a delay in the performance of labor analgesia would lead to a significant increase in morbidity.
There are also financial consequences to the "E" designation. The "E" status adds two units to the anesthesia bill, which can amount to upwards of $200 an epidural, the exact amount of course depends on the specific arrangements for anesthesiology reimbursement a department, group, or individual has. Anesthesiologists who routinely use the "E" designation for billing for labor analgesia could be viewed as billing fraudulently, given the Relative Value Guide's definition of emergency. Depending on the reimbursement per unit, this can quickly add up to a significant amount of potentially illegitimate money, further adding unnecessarily to the costs of health care. In our department, we place approximately 1400 epidurals for parturients each year who have private insurance. At $80/unit this would provide us with an additional $224,000 each year, if we billed this way. But we don't. Imagine how much money this amounts to with over 4 million births in the United States each year. Although reimbursement to anesthesiologists, especially from Medicare and Medicaid, is clearly inappropriately low, it is equally inappropriate to "make it up" by overbilling for labor analgesia.
Labor analgesia is a choice. As urgent as it feels and as quickly as it should and needs to be provided, it is never an emergency. Just because it is not scheduled does not mean it is an emergency. The laboring patient can decide at any moment, even during the procedure, that she does or does not want an epidural. How can that be an emergency? In no other medical circumstance would a patient decide to have an emergency. Labor pain is the expected consequence of pregnancy. Usually it is experienced as a continuum of increasingly severe pain. At the point when a parturient chooses not to experience the pain, she may request to have an epidural placed. Most anesthesiologists when faced with an emergency cesarean section and an "emergency" labor epidural at the same time would deal with the cesarean section first and delay the labor epidural. This is because a labor epidural is not an emergency and should not be designated "E."
1. Saklad M. Grading of patients for surgical procedures. Anesthesiology 1941; 2:281-4
2. New classification of physical status. Anesthesiology 1963; 24:111.
3. Vacanti CJ, Van Houten RJ, Hill RC. A statistical analysis of the relationship of physical status to postoperative mortality in 68,388 cases. Anesth Analg 1970; 49:564-6.
4. Marx GF, Mateo CV, Orkin LR. Computer analysis of post-anesthetic death. Anesthesiology 1973; 39:54-8.
5. Menke H, Klein A, John K et al. Predictive value of ASA classification for the assessment of the perioperative risk. Int Surg 1993; 78:266-70.
6. Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc 2001; 49:1080-5.
7. Pronovost P, Dorman T, Sadovnikoff N et al. The association between preoperative patient characteristics and both clinical and economic outcomes after abdominal aortic surgery. J Cardiothorac Vasc Anesth 1999;13:549-54.
8. Jain KM, O'Brien SP, Munn JS et al. Axillobifemoral bypass: elective versus emergent operation. Ann Vasc Surg 1998;12:265-9.
9. Owens WD, Felts JA, Spitznagel EL. Anesthesiology 1978; 49:239-43.
10. ASA Relative Value Guide 2002, American Society of Anesthesiologists, page xii, Code 99140.