Sam Jones, a healthy 44-year-old male, went skiing and fell, injuring his leg. Sam lay in the snow for hours before being rescued. When Sam arrived by ambulance at the nearest ER, he was diagnosed with an open ankle fracture and total body hypothermia. Sam was taken to the OR for surgical repair of the fracture. What are the appropriate codes you should report for the anesthesiologist?

Question

Quizplus · Accepted Answer

The correct codes for the anesthesiologist in this scenario are 01480-P1, 99116. Code 01480 is for anesthesia for procedures on the lower leg, not including the thigh, which is appropriate for an ankle fracture repair. The modifier P1 indicates a normal, healthy patient, which fits Sam's description before the accident. Code 99116 is for anesthesia complicated by total body hypothermia, which Sam experienced after lying in the snow for hours.

Sam Jones, a Healthy 44-Year-Old Male, Went Skiing and Fell