Wiki In patient H&P w/procedure

Nwright73

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Procedure: The left arm is surveyed w/ the ultrasound. Identification of a vein in subcutaneous tissue superficial to the brachial vein along the medial aspect of the arm is identified. The area is prepped and draped in a sterile fashion, an 18 guage Angiocath is placed into the vein and secured. It flushes easly and aspirates blood. The right upper extremity is then prepped and draped, and the area over the fluctuant abscess is infiltrated with1 % lidocaine with epinephrine and an approxiamately a 2 inch vertical incision over the abscess is made, carried into the subcutaneous tissue and the abscess cavity is entered. Large amount of purulent fluid is expressed, between 1 and 200cc is estimated. The would was then irrigated. Digitally explored. Loculations were broken up and then the abscess is packed with a 2 inch kerlix clean roll
 
If the H&P was done then it was found the need for the procedure I think you should code both. If it was known he was going to need the procedure from a previous visit (day before) the procedure should only be coded. As for the billing, the insurance company may say it is part of the procedure and not pay for both on the professional side, but the hospital should be able to bill for the procedure as an IP on a UB to mirror the professional. It is above and beyond the customary treatment for an IP.
 
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