American Society of Anesthesiologist Classification—Higher Incentives for Higher Scores

To the Editor Changes in medicine do not occur in a vacuum. In a research letter published in a recent issue of JAMA Internal Medicine, Nie et al suggest evidence of upcoding by anesthesiologists but ignore several explanations.¹

First, expanding use of electronic medical records (EMRs) occurred from 2005 to 2013. More complete preoperative assessments are facilitated by such access.^2,3 Second, EMRs can produce unintended errors that affect coding, including the source of the American Society of Anesthesiologists (ASA) classification.⁴ Nonanesthesiologists have been shown to markedly underestimate ASA physical status⁵ out of ignorance, to avoid anesthesia consultation for sedation services, or to allow the use of the Sedasys system (patients with ASA physical status rating 1-2 only). Third, patients are older, sicker, and heavier: sleep apnea—or at least our recognition of it and its risks—is more prevalent, for example.¹ These data show changes in coding practices but are not evidence of upcoding, deliberate or otherwise.