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2 THE MONTHLY NEWSLETTER FOR THE INFORMED HEALTH CARE PROFESSIONAL

ISSUE 7 VOL. 3

Inside this Issue:CMS News Updates ………………. 2CMS to Cut Physicians’ Medicare Payments in 2013 Unless SGR Bypassed2013 Medicare Physician Fee Schedule as of 12/20/2012

Primary Care Gets Recognition for Work in 2013 Changes …………………………. 3Changes to Psychiatry Codes & Table …………………………………. 4 Procedural Coding Changes for 2013 ……………………………………………. 6MMI Limited Time Offers …………………………………………………….16

Every Physician and other qualified healthcare professional should check out the Procedural Coding Changes for 2013 on p. 6

The Medical Business Journal is a monthly source of up-to-date information on all issues affecting the healthcare industry. Its content ranges from medical coding and billing to healthcare reform legislature and beyond. The MBJ is not affiliated in any way with the Department of Health and Human Services, Medicare, or the Centers for Medicare and Medicaid Services. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional services, and is not a substitute for individualized expert assistance. The CPT codes, descriptors, and modifiers are copyrighted by the American Medical Association. For more information, please call MMI at 866-892-2765.

Editor in Chief

Carleigh Benscoter

Contributors

Kathy Dyson

Bob Herman

Layout & Design

Carleigh Benscoter

The Medical Business Journal is brought to you by the Medical Management Institute

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CMS to Cut Physicians’ Medicare Payments 26.5% in 2013 Unless SGR BypassedWritten by Bob Herman | November 2, 2012

This article has been reprinted with permission from Becker's Hospital Review, where it originally appeared. Visit Becker's Hospital Review at www.BeckersHospitalReview.com.CMS has issued its final rule on the Medicare physician fee schedule (pdf) for 2013, saying Medicare reimbursement rates for physicians will be slashed by 26.5 percent on Jan. 1, 2013, unless Congress bypasses the sustainable growth rate. Here are six primary points from CMS' final rule, many of which carried over from the proposed rule in July.

1. Sustainable growth rate. The SGR, which is the formula used to adjust Medicare physician payment rates, is currently expected to cut physician rates by 26.5 percent. However, every year since 2003, Congress has temporarily bypassed the SGR to ensure there would be no cuts to physician Medicare payments, and another temporary "doc-fix" is likely this year during a lame duck session.

2. Primary care emphasis will stand. Primary care physicians and extenders will see increased payments next year, assuming there is an SGR fix, as the final rule solidified new policies in total allowed charges. Family practice physicians will see the largest Medicare payment increases at 7 percent, and several other primary care providers — such as internal medicine physicians, pediatricians, and nurse practitioners — will see payment boosts ranging from 3 to 5 percent. The total allowed charges figures are similar to those that were in the proposed rule.

As stated in the proposed rule, CMS also said a new policy will pay a patient's physician or practitioner to coordinate care in the 30 days following a hospital or skilled nursing facility stay.

3. Specialists will still see reduced charge rates. The proposed rule stated that many specialty physicians will see their Medicare rates decrease, and that carried forward in the final rule as well. Here are some of following specialties that will see the biggest decreases in Medicare total

charge rates/payments: independent laboratory providers (14 percent), neurologists (7 percent), radiation oncologists (7 percent), pathologists (6 percent), interventional radiologists (3 percent) and cardiologists (2 percent).

4. Physician value-based payment modifier and Physician Quality Reporting System. CMS said it will apply the value-based payment modifier — which is a tool that provides different Medicare payments to physicians based on quality of care and cost of care comparisons — to groups that have 100 or more physicians in 2015 instead of groups of 25 or more in the proposed rule.

5. Information technology. The final rule also expanded Medicare telehealth services and simplified reporting within the Medicare Electronic Health Records Incentive Pilot Program for physicians.

6. Certified registered nurse anesthetists. Medicare will now pay CRNAs for providing all services that are allowable under state law and within the full extent of their state's scope of practice.

Attention Health ProfessionalsInformation Regarding the 2013 Medicare Physician Fee Schedule | December 20, 2012

The negative update of 27% under current law for the 2013 Medicare Physician Fee Schedule is scheduled to take effect on January 1, 2013. 

Medicare Physician Fee Schedule claims for services rendered on or before December 31, 2012, are unaffected by the 2013 payment cut and will be processed and paid under normal procedures and time frames.

The Administration is disappointed that Congress has failed to pass a solution to eliminate the sustainable growth rate (SGR) formula-driven cuts, and has put payments for health care for Medicare beneficiaries at risk.  We continue to urge Congress to take action to ensure these cuts do not take effect.  Given the current progress with the legislation, CMS must take steps to implement the negative update.

Under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.  CMS will notify you on or before January 11, 2013, with more information about the status of Congressional action to avert the negative update and next steps.

CMS News Updates

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This year, the news about the physician fee schedule has been about reductions in reimbursements. One area that is continuing to see increases and additional avenues of revenue is the Primary Care Provider (PCP). For 2013, AMA and CMS have introduced the new Transitional Care Management Services. This continues a trend that was put in place in 2011 with the quarterly incentive payment program that augments the Medicare payment by 10% of the Medicare paid amount for primary care services.

For established patients whose medical/psychosocial problems require a moderate to high complexity of medical decision making during a transitional process, PCP’s can now get paid by Medicare around $160 to $230 for care provided during the 30-day period after discharge.

Most PCP’s are already doing a lot of this work, although they may not be documenting it. Who are these patients and what constitutes transitional care management? These patients are patients that are coming FROM an inpatient hospital setting, a partial hospital setting, observation status in a hospital, or from a skilled nursing facility TO their Home, Rest Home, Assisted Living or other domiciliary (discharge). The provider, or his clinical staff, must have contact with the patient or their caregiver within 2 business days of discharge. The contact may be direct via telephone or by electronic means. A medication reconciliation and management must take place no later than the date of the face-to-face visit.

There are two levels of Transitional Care Management Services, driven primarily by the complexity of medical decision making required during the 30-day period after discharge. The first level of Transitional Care Management is reported using CPT® 99495. It requires the initial communication with 2 business days of discharge, involves medical decision making of at least moderate complexity during the service period, and a face-to-face visit with 14 calendar days of discharge. The second level of transitional care management is reported using CPT® 99496. It requires the initial communication with 2 business days of discharge, involves medical decision making of high complexity during the service period, and a face-to-face visit with 7 calendar days of discharge. The initial contact can be made by either the physician or his clinical staff, under his supervision.

One guideline on this is that if two attempts are made to contact the patient in a timely manner but are unsuccessful, and documented and other transitional care management criteria are met, you can still report the service. You may not use these codes during the same month that you use Medical Team Conference codes. Clinical staff services that can be delivered without face-to-face service can include:• Communication regarding various aspects of care

with either the patient or a caregiver/guardian• Home health agency or other community service

communications• Patient or family education on self-management,

independent living and activities of daily living• Assessment of treatment regimen adherence and

medication management• Identification of community and health resources• Facilitating access to care and services needed by

the patient and/or family

Physician or Other Qualified Health Care Professional services that can be delivered without face-to-face service can include:

• Obtaining and reviewing discharge information• Reviewing need for or follow-up on pending

diagnostic tests and treatments• Interaction with OQHCP who will assume or

reassume care of the patient’s problems• Education of patient, family, guardian and/or

caregiver,• Establishment of or reestablishment of referrals

and arring for needed community resources• Assistance in scheduling any required follow-up

with community providers and services.

Documentation of the transitional care management services will be important, by both the clinical staff and the provider. If the provider does not see patients in the hospital, it will be a challenge to identify these patients in a timely manner to actively assist in this management. It will be important for those providers to build relationships with the hospitalist community to facilitate this transition.

Primary Care Gets Recognition for Work in 2013 ChangesWritten by Kathy Dyson | December 20, 2012

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What is an add-on code? An add-on code is a code that can only be used in conjunction with another, primary code and is indicated by the plus symbol (+) in the CPT manual. While basic CPT codes are valued to account for pre- and post-time, add-on codes are only valued based on intra-service time since the pre- and post-time is accounted for in the primary code. In the new Psychiatry codes there are three different types of add-on codes: 1.) Timed add-on codes to be used to indicate psychotherapy when it is done with medical evaluation and management; 2.) A code to be used when psychotherapy is done that involves interactive complexity (and  3.) A code to be used with the crisis therapy code for each 30 minutes beyond the first hour. See above for details about these add-on codes.

NoteSince the new psychotherapy codes are not for a range of time, like the old ones, but for a specific time, the CPT “time rule” applies. If the time is more than half the time of the code (i.e., for 90832 this would be 16 minutes) then that code can be used. For up to 37 minutes you would use the 30 minute code; for 38 to 52 minutes, you would use the 45-minute code, 90834; and for 53 minutes and beyond, you would use 90837, the 60-minute code.

This article has been reprinted with permission from the American Psychiatric Association’s Office of Healthcare Systems & Financing. For 2013 there have been major changes to the codes in the Psychiatry section of the AMA’s Current Procedural Terminology, the codes that must be used for billing and documentation for all insurers. These changes apply to any services provided beginning January 1, 2013.

• A distinction has been made between an initial evaluation with medical services done by a physician (90792) and an initial evaluation done by a non-physician (90791).

• The psychotherapy codes have been simplified and expanded to include time with both the patient and/or family member: There are now just three timed codes to be used for psychotherapy in all settings (90832- 30 minutes; 90834-45 minutes; 90837- 60 minutes) instead of a distinction made by setting and whether E/M services were provided. When psychotherapy is done in the same encounter as an E/M service, there are timed add-on codes for psychotherapy (indicated in CPT by the + symbol) that are to be used by psychiatrists to indicate both services were provided (90833 -30 minutes, 90836 - 45 minutes, 90838 – 60 minutes). The time for each psychotherapy code is now described as being as time spent with the patient and/or family member, a change from the previous psychotherapy code times, which denoted only time spent face-to-face with the patient.

• In lieu of the separate codes for interactive psychotherapy, there is now an add-on code for interactive complexity, which may be used when the patient encounter is made more complex by the need to involve people other than the patient (90785). This add-on can be used with initial evaluation codes (90791 and 90792), with  the psychotherapy codes, with the non-family group psychotherapy code (90853), and with the E/M codes when they’re used in conjunction with psychotherapy services. Although it is expected this code will be used most frequently in the treatment of children, it can be used any time the interaction with the patient and/or family member is more complex than normal or when other parties must be involved. The CPT manual includes specific guidelines as to what constitutes interactive complexity that should be understood before this add-on code is used. Documentation must clearly indicate exactly what that complexity was.

• Another change is that a new code has been added for psychotherapy for a patient in crisis (90839).  When a crisis encounter goes beyond 60 minutes there is an add-on code for each additional 30 minutes (90840). This code was developed at the behest of the National Association of Social Workers, and it is expected that psychiatrists will generally use a high level E/M code when providing care for a patient in crisis. The CPT manual has guidelines as the what constitutes a crisis and permits the use of this code.

• Code 90862 has been eliminated, and psychiatrists will now use the appropriate evaluation and management (E/M) code when they do pharmacologic management for a patient. When psychotherapy is done during the same session as the pharmacologic management, one of the new psychotherapy add-on codes should be used along with the E/M code. (A new code, add-on code +90863, has been created for medication management when done with psychotherapy by the psychologists in New Mexico and Louisiana who are permitted to prescribe, but this code is not to be used by psychiatrists or other medical mental health providers).

Changes to the Codes2012 American Psychiatric Association | All Rights Reserved

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American Psychiatric Association CPT Coding Resources for APA Members

CPT Coding Changes for 2013

CPT® five-digit codes, descriptions, and other data only are copyright 2011 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. CPT® is a registered trademark of the American Medical Association (AMA).

Initial Psychiatric Evaluation (formerly 90801 or new patient E/M code)

90791, Psychiatric diagnostic evaluation (no medical services)

90792, Psychiatric diagnostic evaluation (with medical services) (New patient E/M codes may be used in lieu of 90792)

Psychotherapy (formerly 90804-90808, 90816-90821) For use in all settings; time is with patient and/or family)

90832, psychotherapy, 30 minutes

90834, psychotherapy, 45 minutes

90837, psychotherapy, 60 minutes

Evaluation Management (E/M) and Psychotherapy (formerly 90805-90809, 90817-90822)

Appropriate E/M code (not selected on basis of time), and 90833, 30-minute psychotherapy add-on code

Appropriate E/M code (not selected on basis of time), and 90836, 45-minute psychotherapy add-on code

Appropriate E/M code (not selected on basis of time), and 90838, 60-minute psychotherapy add-on code

Medication Management (formerly 90862 or E/M code)

Appropriate E/M code (99xxx series)

Interactive Psychotherapy (formerly 90802, 90810-90815, 90823-90829, 90857) For use with the psychiatric evaluation codes, the psychotherapy and

psychotherapy add-on codes, and the group (non-family) psychotherapy code

90785, interactive psychotherapy

Crisis Psychotherapy (new)

90839, psychotherapy for crisis, first 60 minutes (Appropriate E/M code may be used in lieu of 90839)

90840, psychotherapy for crisis, each additional 30 minutes

These changes take effect January 1, 2013. Questions – Go to http://www.psychiatry.org/practice, or call 800-343-4671 or send an email to hsf@psych.org. To purchase a copy of the 2013 CPT manual call the AMA at 800-621-8335 or go to https://catalog.ama-assn.org/Catalog/home.jsp .

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There are over 600 changes to Procedural Coding that will be in effect on January 1, 2013. Imagine if this article described every one. It would be a sure cure for insomnia. As Medical Billing and Coding professionals, it is important to understand the broader category of changes and to do in-depth study of specialties in which we work every day. All of us should spend time with the Evaluation and Management Services section, as that crosses specialties and has some exciting changes for the Primary Care providers this year.

In our profession, it is important that we always continue to grow our knowledge of the industry. As Martin Palmer, an author and translator of books points out: “The secret to mastery in any field is to forever be a student.” This certainly applies to our field today! Even as this article is being published, changes are still taking place. As the AMA identifies things that need corrections or clarifications, they issue an erratum. An erratum is simply a word of Latin origin that means a change or correction to a publication. The group of erratum’s together is called the errata (multiple changes).

Out of necessity, all changes are not reflected in this article. You should review the information presented here and understand the areas of change. Education of your providers on the changes is also critical to a successful start to the New Year. Start using the 2013 CPT® manual, in conjunction with the errata, to be sure that you use only the latest codes in preparing claims for 2013.

Sign up to be notified of any future changes to the CPT® errata accessed via the following link: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/announcements-reports/e-mail-notifications.page

CPT® Nomenclature NeutralityWhile the number of changes listed in the 2013 CPT® changes manual from the AMA may seem overwhelming if you look at the actual number of changes, it can be far less intimidating if you realize that many of the changes made can be understood under this single bit of terminology; that terminology is that the CPT® Nomenclature reflects neutrality

about who can render services. Therefore, you see a lot of changes when reviewing update documents that show the word “qualified physician” or “physician” as being removed and replaced with “physician or other qualified health care professional”.

So, let’s look at what the AMA has called CPT® Nomenclature Neutrality: “A nomenclature is a system or set of terms or symbols in a particular discipline.” Therefore, the Current Procedural Terminology (CPT®) Nomenclature is a list of medical terms that we use in medicine to describe procedures and services.

In the past, many of the guidelines, parenthetical instructions, and examples in the CPT® Nomenclature describe a ‘physician’ as the person performing a specific service. Since inception, many of the procedures and services have been described in terms of a ‘qualified physician’ performing the service. It is important as we become more and more specialized in medicine that the list of terms used to bill for our services, and the examples and guidelines used by payers to approve our services for reimbursement, allows for any qualified professional or entity to conduct that service or procedure as determined by the laws and guidelines of their location.

Therefore, AMA has chosen 2013 as the year to introduce their neutrality as to who/what entity performs a service. It also includes distinctions between a “qualified physician or other health care professional” and “clinical staff”. So, if a hospital, clinical laboratory, nurse practitioner or other professional is licensed to perform certain services, the language in the CPT® now makes it clear that a physician or other qualified health care professional can perform that service and be consistent with the definition and examples in the CPT® books.

A limited number of code series have been created or modified to improve or distinguish when it is significant that a physician, instead of a qualified health care professional, is required to perform the

Procedural Coding Changes for 2013An Overview | By Kathy Dyson

“As Martin Palmer, an author and translator of books points out: ‘The secret to mastery in any field is to

forever be a student’.”

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service. Now the alignment between CMS and other payers with the CPT® definitions of service should be aligned.

The professionals distinguished by the phrase “physician or other qualified health care professional”

differ from clinical staff in one significant component. A clinical staff member works under the supervision of a “physician or other qualified health care professional” and is not allowed by law, regulation or facility policy to individually report that professional service.

Explicit Code RangesAn effort was made in the 2013 procedural coding changes to include more explicit code ranges in the guidelines on use and in examples. For example, in the past, you might have been directed to the title of specific services like “office visit codes”, etc. Now those codes will be specifically identified as “new or established patient office or other outpatient services including (99201-99215).”

This change to include the explicit code ranges when providing coding tips and guidelines was driven by the need to provide consistency across older and newer sections of the nomenclature. In addition, it is an effort to support the opposition to the practice of arbitrary recoding and/or bundling by payers. It should also assist billing and coding professionals in submitted error free claims and reduce appeals.

This refinement in the definitions will make our use of the guidelines easier by providing clearer direction and eliminate the time spent cross-referencing the various titles and subsections.

Evaluation & Management ServicesThe changes in the Evaluation & Management Services (E/M) codes include new codes this year. In the NEW Transitional Care Management Services section you will find two new codes and in the NEW Complex Chronic Care Coordination Services section you will find three new codes. These new sections are explored in a separate article titled “Primary Care gets Recognition for Work in 2013 changes” on page 3 of this newsletter. In addition to the new sections, there are clarifications and revisions. Of course, all of this is in addition to the Nomenclature Neutrality and Explicit Code Range changes.

Changes to the observation or inpatient hospital care codes 99234 – 99236 have had typical service times added for clarity.

Who & What is an ‘Other Qualified Health Care

Professional’?Q. What is an Other Qualified Health Care

Professional?A. “A ‘physician or other qualified health care

professional’ is an individual who is qualified by education, training, licensure/regulation (when

applicable), and facility privileging (when applicable) who performs a professional service

within his/her scope of practice and independently reports that professional service.”

Q. Is there a difference between an other qualified health care professional and

clinical staff?A. “These professionals [other qualified health care professionals] are distinct from ‘clinical

staff.’ A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and

who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does

not individually report that professional service.”

Q. Why were the terms “physician,” “qualified health care professional,” and/or “individual”

added and/or taken away?A. The CPT® revisions to codes, guidelines,

and/or parenthetical instructions were done with the intent of provider neutrality in the CPT®

code set.

As stated in the CPT®; “Throughout the CPT® code set the use of the terms such as 'physician,’

‘qualified health care professional,’ or ‘individual’ is not intended to indicate that other entities may not report the service. In selected

instances, specific instructions may define a service as limited to professional or limited to other entities (eg, hospital, or home health

agency).”

[Source: Current Procedural Terminology (CPT®), Fourth Edition]

“An erratum is simply a word of Latin origin that means a change or correction to a publication. “

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Prolonged Services Subsection Includes a change to note the removal of psychotherapy codes 90809 and 90815 from the parenthetical notes since they were deleted. One additional change was that the parenthetical was amended to include the Hospital Inpatient Services. You will note the use of explicit code ranges in those changes. They also removed psychotherapy codes 90822 and 90829 from the parentheticals, as these codes were deleted for 2013.

Nursing Facility Services GuidelinesThe nomenclature neutrality went a step further than the AMA intended. Therefore, an errata was issued that strikes the “and other qualified health care professional” from the guidelines because the AMA has set the standard that an initial assessment in the nursing facility can be done by a licensed physician only.

Inpatient Neonatal and Pediatric Critical Care Services, as well as Initial and Continuing Intensive Care Service guidelines were modified for 2013. If you work with neonatal or pediatric critical care, it is important to read and understand these new examples and guidelines. The codes 99471-99476 should be used for infants and children through their fifth year. The codes in this explicit range differentiate from less than 2 years and 2 years through five years of age. Six years of age and older requiring critical care should be reporting with 99291-99292.

The guidelines were also clarified regarding the transfer of a neonate or infant that is critically ill. The transferring provider and receiving provider must use the correct codes and the guidelines have been expanded and examples provided to assist in correct coding. Note that the 99485 and 99486 CPT® codes are now sequenced to be grouped with the 99466 and 99467 codes in 2013.

Here is an example of how 99485 and 99486 is used from the CPT® Changes 2013 – An insider’s View:

A 34-week critically injured neonate is delivered at a level I hospital and the community provider requests a transfer to the physician’s hospital. The ground transport team consisting of a nurse and respiratory therapist is dispatched to the

level I hospital. After the team evaluates the patient, they contact the control physician to discuss the case. The physician and team remain in two-way communication and decide together on the appropriate management and interventions for the child before and during transport back to the control physician’s hospital. The control physician reports 99485 for the first 30 minutes and 99486 for each additional 30 minutes.

A late correction was issued by the AMA for the Initial Neonatal Intensive Care section on 12/12/2012.

Here is the updated information:

Remove reference to weight “1500-5000 gms” from the (E/M) Initial Neonatal Intensive Care table.

A late correction was issued by the AMA for the Continuing Neonatal and Infant Inpatient Low Birth-weight intensive care section on 12/12/2012.

Here is the updated information:

Initial Neonatal Intensive CareInitial Neonatal Intensive Care

Code 99477

Age 28 days of age or younger

Weight 1500-5000 gms

Presenting Problem Requires Intensive Observation, Frequent Interventions/Other Intensive Care Services

Continuing Neonatal and Infant Inpatient Low Birth-Weight Intensive Care

Continuing Neonatal and Infant Inpatient Low Birth-Weight Intensive Care

Continuing Neonatal and Infant Inpatient Low Birth-Weight Intensive Care

Continuing Neonatal and Infant Inpatient Low Birth-Weight Intensive Care

Continuing Neonatal and Infant Inpatient Low Birth-Weight Intensive Care

Code 99478 99479 99480 See 99231-99233

AgeAge 28 days of age or less28 days of age or less28 days of age or less

Weight 1500 gms or less

1500-2500 gms

2501-5000 gms

+5000 gms

Presenting ProblemPresenting Problem

RecoveringRecoveringRecovering

OOPS!

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Remove reference to age “28 days of age or less” from the (E/M) Continuing Neonatal and Infant Inpatient Low Birth-Weight Intensive Care table.

Anesthesia

The Anesthesia section has no changes this year, other than the nomenclature neutrality updates.

Surgery ChangesSurgery has 47 additional new codes and deletions of 11 codes. General surgery had no changes for 2013.

Integumentary System changes15740 Flap, island pedicle was modified to add: “Requiring identification and dissection of an anatomically named axial vessel.”

Musculoskeletal System changes➡ Grafts (or Implants) the add on codes

20930-20938 now have a parenthetical to “Use 20930 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-222612, 22630, 22633, 22634, 22800-22812, 0195T, 0196T”

➡ With this change also came clarification of code 0232T to use in harvesting, preparing and injecting platelet-rich stem cells derived by bone marrow aspiration. This is in contrast to code 38220. Look for an article regarding this in January, 2013 AAOS Now publication.

Spine (Vertebral column) changes➡ Vertebral Body, Embolization or Injection - The

Moderate sedation symbol has been added to the add-on code 2252 for each additional thoracic or lumbar vertebral body, as it is an inclusive component of the code and should not be separately reported.

➡ Arthrodesis – A new code 22586 has been added to report arthrodesis using the presacral interbody technique. It includes all services required to perform the fusion procedure, including the preparation of the disc space, discectomy at this level, posterior instrumentation, imaging necessary for provision of the procedure and bone grafting performed at the level of arthrodesis.

➡ This section and Spinal Instrumentation include new parentheticals on appropriate use of the add-on codes with the primary procedure. Spinal issues addressed also include changes to parentheticals regarding code 0196T – look for more on this in Category Code III changes.

Shoulder changesRepair, Revision and/or Reconstruction – two new codes➡ 23473 – Revision of total shoulder arthroplasty,

including allograft when performed; humeral OR glenoid component

➡ 23474 - Revision of total shoulder arthroplasty, including allograft when performed; humeral AND glenoid component

Here is an example:

A 55-year-old male had a total shoulder arthroplasty 17 years ago. He now has pain and limited motion with radiographic evidence of component loosening. He undergoes revision of the humeral component. The procedure for the revision is 23473 –Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

Humerus (Upper Arm) and Elbow changesRepair, Revision and/or Reconstruction – two new codes

➡ 24370 – Revision of total elbow arthroplasty, including allograft when performed; humeral OR ulnar component

➡ 24371 - Revision of total shoulder arthroplasty, including allograft when performed; humeral AND ulnar component

Application of Casts and StrappingStrapping Any Age – one deleted code & parentheticals updated

Respiratory SystemTrachea and Bronchi – Four new codes added to this section to report bronchoscopy services for bronchial valves and two new codes for bronchial thermoplasty.

➡ 31647, 31648, 31649 and 31651 were added in bronchoscopy to allow accurate reporting of insertion of valves by initial and additional lobes, with distinction for removal of bronchial values in the initial and additional lobes lobe.

➡ Codes 31660 and 31661 were also added to allow accurate reporting by one or multiple lobes with bronchial thermoplasty.

➡ CPT® 31656 has been deleted and is replaced by 31899. CPT® 31715 was deleted. The emphasis on the changes in this area is that for each endoscopic procedure, you must code the appropriate endoscopy of each anatomic site examined. Further clarification is given on diagnostic bronchoscopy being included as a part of surgical bronchoscopy when done by the same

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physician and codes 31622-31649 include fluoroscopic guidance, if used.

Lungs and Pleura ➡ 32420 was deleted. Use 32405 to report. 32421

and 32422 were deleted. Use 32554 and 32555 to report.

➡ 32551 has been modified to read: Tube thorascostomy, includes connection to drainage system (e.g. water seal), when performed, open (separate procedure) This open procedure excludes a pigtail catheter, because it does not require a knife and clamps.

➡ CPT® codes 32554-32557 are new codes to correctly address pleural fluid aspiration and percutaneous plural drainage procedures.

➡ A new category has been added for Stereotactic Body Radiation Therapy (SRS/SBRT). CPT® 32701 has been added to represent the distinct procedure which involves collaboration between a surgeon and radiation oncologist. The surgeon identifies the target for radiation therapy. This code would be used by the surgeon. The radiation oncologist uses the appropriate codes for clinical treatment planning, dosimetry, physics and treatment delivery and management.

Cardiovascular SystemThe cardiovascular system has a lot of changes in CPT® coding this year. In fact, if you work in the specialty, you will want to do some extra review and work to understand these changes. We will only cover the highlights in this article. The potential to impact revenue for cardiologists is high if the specific guidelines and appropriate use of modifiers are not followed and the new codes applied correctly.

➡ Heart and Pericardium – CPT® 33225, an add-on code, has been modified to allow billing now for the “pocket revision” if relocating to another site.

➡ New codes 33361 – 33365 and 0318T have been added to report transcatheter aortic value replacement, with specific codes for each approach. This procedure requires two physician operators and all components of this procedure are reported using modifier 62. It is important to understand all of the work that is included in these codes, as the individual components will now bundle to the new code. This is a limited procedure for now, as there are only a few surgeons doing this procedure. It is primary for patients who are declared inoperable for the open technique. They need a second opinion from a cardiothoracic surgeon to indicate this per CMS guidelines.

➡ New add on codes 33367 – 33369 are paired with the new 33361-33365 and 0318T based on approach, when cardiopulmonary bypass support

is required. Add-on must be reported by a cardiothoracic surgeon and no Modifier 62.

➡ Four new codes and a new heading have been added for percutaneous ventricular assist device (VAD) procedures. 33990- 33993 were added. 33990 is for insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only. 33991 is for the same thing but with both arterial and venous access, with transseptal puncture. 33992 is for removal of percutaneous ventricular assist device at separate and distinct session from insertion. 33993 is repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion. All of these are under moderate sedation. Guidelines and rationale are all significant in this space and should be studied for appropriate use of modifiers and definitions of distinct sessions.

Arteries and Veins 12 deleted codes and 8 new codes were created to address the duplication of work across the carotid angiography codes.

➡ Codes 36221 through 36228 describe services around arterial catheter placement. Distinctions between nonselective or selective placement are made by code and include the diagnostic imaging of the aortic arch, carotid or vertebral arteries. This bundling of procedures is one of consistent themes in the changes to cardiology for 2013. Extensive guidelines on when to use each and multiple examples are included in the CPT® Changes 2013 – An Insider’s view. 37197 is a new code for the transcather retrieval, percutaneous, of intravascular foreign body including the radiological supervision and interpretation and imaging guidance, when performed. This is for retrieval of a fractured venous or arterial catheter. For percutaneous retrieval of a vena cava filter, use 37193. Codes 37201, 37203 and 37209 are deleted. See guidance in CPT® 2013 for replacement codes.

➡ The codes 37211-37214 have been resequenced. They are for use with Transcatheter therapy. Codes are based on an entire day of treatment. Only one of the four codes can be used per day.

Hemic and Lymphatic Systems Bone Marrow or stem cell services/procedures

➡ Parentheticals added for clarity on needle aspiration of bone marrow for the purposes of bone grafting, use 38220. Do not use 38220 – 38230 for bone marrow aspiration for platelet rich stem cell injection. Use code 0232T.

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➡ HPC codes 38240, 38241 and new code 38243 have been moved into their own section for Transplantation and Post-transplantation cellular infusions. Codes 38240 and 38241 have been revised in an effort to provide betters guidelines for use. The new code 38243 is for an HPC boost.

➡ Further guidance is provided in this section on cryopreservation, freezing and storage as well as thawing and expansion of HPC for transplantation use.

Digestive System Esophagus section has had code 43234 deleted. This code was for reporting upper gastrointestinal panendoscopy. It was not commonly used. However, it can be better reported using 43235. ➡ Codes 43206 and 43252 were added to identify

real-time cellular observation of mucosal tissue during an endoscopy procedure, with moderate sedation. The actual contrast is not included in these codes and should be billed separately. These new codes can be used for both diagnostic and therapeutic information.

Stomach Section New guidelines for Bariatric Surgery and Laparoscopy have been included. Specifically, the parenthetical: “For laparascopic implantation, revision, replacement, removal or reprogramming of vagus nerve blocking neurostimulator electrode array and/or pulse generator at the esophagogastric junction, see 0312T-0317T” was added after 43648, 43775 and 43882.

Intestines section Updates have been made to reflect emerging treatment of Clostridium difficile (or c-diff). This new code 44705 was added for preparation of fecal microbiota (slurry) for installation, including assessment of donor specimen. Medicare has a different code, G0455 for this procedure.

Urinary SystemBladder has one new code.

➡ 52287 – Cystourethroscopy, with injections for chemodenervation of the bladder primarily for neurogenic incontinence. The chemodenervation agent is reported separately.

Nervous System➡ Neurostimulators (peripheral nerve) Code 64561

was revised to indicate that image guidance is included if performed in the procedure and should not be reported separately.

➡ Destruction by neurolytic agent…chemodenervation. Codes 64600-64681 include

the injection of therapeutic agents and should not be reported separately. The supply of the chemodenervation agent is reported separately. Guidance is provided in the parentheticals about appropriate use of modifier 50.

➡ A new code 4615 – chemodenervation of muscles innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral was added. This is used for Bell’s Palsy patient and chronic migraine treatment.

Eye and Ocular Adnexa ➡ Anterior Segment – Code 65800 was modified to

Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous. This caused the deletion of 65805, which was the add-on code for therapeutic release of aqueous and is now bundled.

➡ Ocular Adnexa code 67810 was changed from Biopsy of eyelid to: Incisional biopsy of eyelid skin, including lid margin.

➡ AMA has warned that code 92100 is probably being reported inappropriately. If you work in ophthalmology, you want to verify the use of this code is appropriate. It is on the CMS High frequency report. This is a rare code to use with all the other options available in the treatment of glaucoma.

RadiologyDiagnostic Radiology (Diagnostic Imaging) ➡ Chest➡ Deleted 71040 and 71060 – Bronchography has

now been replaced by Computer Tomography (CT)➡ Spine & Pelvis➡ Revised 72040 - Radiologic examination, spine,

cervical 3 views or less (from 2)➡ Revised 72050 - Radiologic examination, spine,

cervical 4 or 5 views➡ Revised 72052 - Radiologic examination, spine,

cervical 6 or more views➡ Vascular➡ Deletion of angiography supervision and

interpretation codes 75650, 75660, 75662, 75665, 75671, 75676, 75680, and 75685. New codes 36221-36228 replaced these codes as they bundled the supervision and interpretation services into the primary procedure

➡ Modified codes 75896 and 75898 to clarify that thrombolytic infusion should be reported separated with 37211-37214

➡ Deleted code 75900 as it is now bundled into 37211-37214

➡ Deleted code 75961, use 37211 to report

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➡ Codes 76376 and 76377 for 3D rendering with interpretation and reporting of computed tomography, MRI, US or other tomographic modality have parenthetical notes to cover changes in nuclear medicine codes

Diagnostic Ultrasound Updated to reflect nomenclature neutrality and parenthetical notes were added or revised to reflect new codes.

Nuclear MedicineThe codes 78000-78011 for thyroid imaging were deleted. To report these see codes 78012-78014.

➡ New codes 78012-78014 were added to handle the bundling of thyroid uptake and imaging procedures to include stimulation, suppression or discharge.

➡ Code 78070 was modified to specify that the Parathyroid planar imaging includes subtraction, when performed.

➡ New Codes 78071 and 78072 were added to accommodate SPECT (Single-photon emission computed tomography) and SPECT/CT.

Pathology and LaboratoryThis section of the CPT® code set has numerous changes. No detailed information is provided in this section. Instead, a summary is provided. If this is your specialty, it is important to examine the changes in Molecular Pathology, Chemistry, Immunology and Microbiology. All other sections remain unchanged.Evocative/Suppression Testing guidelines have been revised to encompass all of the therapeutic infusion codes. If you have used prolonged service codes for infusion therapy, be sure to read the new guidelines, as this is no longer appropriate.

Molecular pathology Added 14 new codes and changed 9 codes. In addition, new definitions were included for inversion, loss of herozygosity and uniparental disomy. 13 new codes were added to Tier 1 relating to molecular pathology procedures.

➡ Codes 81201-81203 were added for assessing the presence of adenomatous polyposis coli (APC), which may indicate attenuated FAP (Familial Adenomatosis Polyposis). Familial adenomatous polyposis (FAP) is an inherited condition in which numerous polyps form mainly in the epithelium of the large intestine. While these polyps start out benign, malignant transformation into colon cancer occurs when not treated.

➡ Code 81235 is used to assess Epidermal Growth Factor Receptor (EGFR), a possible indicator of non-small cell lung cancer.

➡ Code 81252, 81253 and 81254 are used to look for indications of nonsyndromic hearing loss.

➡ Codes 81321-81323 are used to screen for possible Cowden syndrome.

➡ Codes 81324-81326 are used to look for indicators of Charcot-Marie-Tooth disease.

➡ The nine modified codes are Tier 2 molecular pathology codes that were revised to include additional tests. They are: 81400-81408.

➡ A new code (81479) for reporting an “Unlisted molecular pathology procedure” was added.

Multianalyte Assays with Algorithmic Analyses (MAAAs)This section is new and addresses in vitro diagnostic multivariate index assays. The new codes are:

➡ 81500 – a serum test that determines the menopausal status as a numeric score

➡ 81503 – a multianalyte assay used to determine a risk index for ovarian malignancy

➡ 81506 – a multianalyte assay that develops a risk score with the probably of developing a disease(such as the risk of diabetes).

➡ 81508-81512 are used to provide maternal serum screening

➡ Code 81559 is used to report unlisted MAAA procedures.

Chemistry ➡ Codes 82009 and 82010 were updated to reflect

current clinical practice. These procedures are used to screen for, detect and monitor Diabetic KetoAcidosis (DKA) in diabetics.

➡ Code 82777 is a new code for an enzyme immunoassay to detect Galectin-3.

Immunology ➡ Codes 86152 and 86153 are added to accurately

report the test that helps determine disease prognosis in cancer patients and help determine appropriate treatment. This is called Circulating Tumor Cells (CTC) enumeration.

➡ Code 86711 was added to help determine the disease prognosis and aid in treatment planning.

Tissue TypingNew codes 86828 through 86835 are used to report antibody to human leukocyte antigen (HLA) solid phase assays.

Microbiology

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Updated parentheticals in this section were added to accommodate the deletion and replacement of the stacking codes 83890-83914.

➡ Modified codes 87498, 87521, 87522, 87535, 87536, 87538 and 87539 were all updated to include the reverse transcription that is required when working with RNA to detect infectious agents.

➡ New codes 87631- 87633 are used for new infectious agent detection by nucleic acid for respiratory virus, with more viral targets identified.

➡ New codes 87910 and 87912 are used for determining drug resistance and treatment options for viral diseases.

➡ New code 88375 is for Optical endomicroscopic image(s), and is clarified for real-time or referred interpretation and report. It cannot be used with 43206 or 43252 surgical codes.

MedicineWith a total of 51 new codes and 47 deletions, Medicine was one of the expanded areas in the 2013 CPT® nomenclature. There were also changes here for Nomenclature Reporting Neutrality. It was an extensive recipient of the Explicit Code Ranges changes.

In this section, the Psychiatry subsection has undergone significant changes, with 24 deleted individual psychotherapy codes and replaced with six new psychotherapy codes. Please see the separate article “Changes to the Codes” and coding table from the American Psychiatric Association on pages 4 & 5 of this issue for more information on these changes.

The Cardiovascular subsection has many changes, including a new coding structure for percutaneous coronary interventions with 13 new codes and accompanying guidelines. The Intracardiac Ablation codes were deleted and 3 new codes were added to combine comprehensive electrophysiologic evaluation with intracardiac ablation of arrhythmogenic focus services.

The Allergy Testing codes and Neurology and Neuromuscular section all have changes, as do the Sleep Testing, Nerve Conduction Tests, Intraoperative Neurophysiology and Autonomic Function Tests all have new and revised codes.

Vaccines and ToxoidsNew code 90653 was added, PENDING FDA APPROVAL, for influenza vaccines with adjuvants. Adjuvants increase the immune response. Follow the updates on this code by the AMA.

➡ Codes 90655, 90656, 90657 and 90658 were updated to add “trivalent” to the description of the influenza vaccine, in preparation for the new quadrivalent vaccines which are expected in 2013.

➡ Code 90672 was added for use of the new quadrivalent influenza vaccine anticipated in 2013.

➡ Code 90739 is new for a 2-dose Hepatitis B vaccine with adjuvant. PENDING FDA APPROVAL – follow updates on this code by the AMA.

➡ Code 90746 was revised to reflect the 3-dose HepB vaccine already in place.

GastroenterologyCode 91112 is new and replaces code 0242T for measurement of gastrointestinal transit and pressure measurement, stomach through colon with a wireless capsule. It includes the interpretation and report.

Still Confused

About MAAAs?

These tests are also known as in vitro diagnostic multivariate index assays.  These tests are run and then the results put through proprietary algorithms and generate a numeric score or index. They are generally specific to a vendor. An example would be: a female of middle age presents with discomfort in her pelvic regions. An ovarian mass is identified.  Typical transvaginal ultrasound reveals in indeterminate, complex-appearing solid mass and surgery is recommended for removal. The OVA1 test ( a MAAA) is run to help distinguish between cancer and non-cancerous results. The index score is used to determine whether a gynecologic oncologist is appropriate or not.

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OphthalmologyCode 92286 and 92287 were revised from Special anterior segment photography to Anterior segment imaging with interpretation and report with specular microscopy and endothelial cell analysis.

CardiovascularCodes 92980-92984, 92995 and 92996 have been deleted, and 13 new codes created to report these procedures. A new Subsection within Medicine/Cardiovascular/Therapeutic Services called Therapeutic Services and Procedures was added. This change was made because the complexity of the current percutaneous coronary stent placement and angioplasty procedures was not adequately reflected in the old codes.

➡ The new codes 92920, 92921, 92924, 92925 all address the percutaneous transluminal coronary angioplasty with major coronary arteries or branches.

➡ The new codes 92938 and 92929 address the percutaneous transcather placement of stents in major coronary artery or branch.

➡ The new codes 92933 and 92934 are for reporting percutaneous transluminal atherectomy with intercoronary stents with coronary angioplasty, when performed in major coronary artery or branch and each additional major artery. [This is when clearing plaque from the artery while placing the stent.

➡ The new codes 92943 and 92944 are for Percutaneous transluminal revascularization of chronic total occlusion in a coronary artery, branch or bypass graft, any combination of intracoronary stent, atherectomy and angioplasty for a single vessel and 92944 is the add on code for each additional artery, branch or bypass graft.

➡ Intracardiac Electrophysiological Procedures/Studies. Intracardiac catheter ablation codes 93651 and 93652 were deleted and three new codes 93653, 93654 and 93656 were established, which combine comprehensive electrophysiologic evaluation with intracardiac catheter ablation of arrhythmogenic focus services. Codes 93755 and 93657 were established to report intracardiac catheter ablation of a discrete mechanism of arrhythmia, distinct from the primary ablated mechanism.

Allergy Testing95010 – Percutaneous allergy tests of all types and 95015 – Intracutaneous allergy tests of all types have been deleted. To report, see 95017 and 95018.

➡ New testing procedure utilizes venoms or drugs/biologicals rather than differentiating primarily based on the technique used. 95017 uses venoms

and 95018 uses drugs/biological and not the method of testing.

➡ Code 95075 - Ingestion Challenge Testing has been deleted. It was replaced by 95076 for total initial testing time of 120 minutes and the add-on code of 95079 for each additional 60 minutes of testing.

Neurology and Neuromuscular Procedures95920 – Intraoperative neurophysiology testing, per hour, has been deleted.

Sleep Medicine Testing Two new codes, 95782 and 95783 were added to report pediatric polysomnography for less than 6 years old. As a results of this addition, codes 95808 was revised to include the “any age” and codes 95810 and 95811 were revised to include age 6 years or older.

Nerve Conduction Tests Old nerve conduction study codes 95900, 95903 and 95904 were deleted and replaced with seven new nerve conduction codes:

➡ 95907: Nerve conduction studies 1-2 studies➡ 95908: 3-4 studies➡ 95909: 5-6 studies➡ 95910: 7-8 studies➡ 95911: 9-10 studies

Significant Changes for Allergy Clinics

A 35 year old female presents with a history of adverse reaction to a sting by an insect that includes mild chest discomfort. Venom allergy testing is done, with the allergist performing 27 total tests, including percutaneous and intracutaneous tests of venoms with positive and negative controls.

What code will you use to report the testing?

Answer: 95017

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➡ 95912: 11-12 studies➡ 95913: 13 or more studies

Intraoperative Neurophysiology Intraoperative Neurophysiology testing code 95920 was deleted and replaced with two new neurophysiology monitoring cases:

➡ 95940: Add-on code for continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes

➡ 95941: Add-on code for continuous intraoperative neurophysiology monitoring from outside the operating room, (remote or nearby) or for monitoring of more than one case while in the operating room, per hour.

Autonomic Function TestsA new combined code was created for instances when both parasympathetic and adrenergic function types of autonomic testing are performed together, and to distinguish use of the tile table during automatic testing.

➡ Code 95924 is the combined testing with at least 5 minutes of passive tilt table during the encounter.

➡ 95943 was established to report this testing without the use of a tilt table.

Evoked Potentials and Reflex TestsCodes 95934 and 95936 were deleted. To report H-reflex testing, see 95907-95913.

Category II and III ChangesThe changes in Category II are not as impactful as previous years. Seven new codes were added, 1 was deleted and repurposing several of the Category II codes for new measures. A new measure set for inflammatory bowel disease was added.

➡ New Measure code 1052F is for type, anatomic location and activity all assessed for Inflammatory Bowel Disease (IBD).

➡ 3517F is new for Hepatitis B virus status assessed and results interpreted within one year prior to receiving a first course of anti-TNF therapy (IBD)

➡ 3520F is new for Clostridium difficile testing performed (IBD)

➡ 3750F is new for Patient not receiving dose of corticosteroids greater than or equal to 10mg/day for 60 or greater consecutive days (IBD)

➡ 4069F is new for reporting venous thromboembolism prophylaxis received (IBD)

➡ 4142F is new for Corticosteroid sparing therapy prescribed (IBD)

➡ 6150F is new for patient not receiving a first course of anti-TNF therapy (IBD)

Changes in Category III include 28 new codes, revision of 3 codes and deletion of 12 codes. These codes for emerging technologies and are not detailed in this article. CPT® Category III codes are not referred to the AMA-Specialty RVS Update Committee (RUC) for valuation because no relative value units (RVUs) are assigned to these codes. Payment for these services or procedures is based on the policies of payers and not on a yearly fee schedule. It is important to keep up to date on these categories by access the CPT® web site. A future edition of the newsletter will discuss these new codes in detail.

Appendices Updates

Appendix A has new guidance on use of Modifier 62.

➡ Appendix I removed the Genetic Testing Code Modifiers because the genetic testing has been adequately updated in the molecular laboratory procedures with 2012 and 2013 changes.

➡ A new Appendix O was added that address the complexities of Multianalyte Assays with Algorithmic Analyses.

Be sure to review the latest errata document and posting on the AMA CPT® web site to keep this section up to date.

[CPT® five-digit codes, descriptions, and other data only are copyright 2011 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. CPT® is a registered trademark of the American Medical Association (AMA). ]➡

16

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3. Introducing Kathy DysonThe Medical Management Institute is very proud to introduce a new instructor to our team; Kathy Dyson. Ms. Dyson will play a huge role in content control, as well as in supporting you the student. Introduce yourself by emailing Kathy@dysoncs.com.

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MMI Updates1. Holiday Gift CardBy now, all of our alumni and current members should have received a MMI $500 holiday gift card in the mail. This can be applied towards any of our certification courses, and is completely transferrable. If you did not receive yours, please email info@mmiclasses.com to be sent an electronic version.

2. 2013 RMC Update Exam on LearnerNationThis combined Nov/Dec 2012 MBJ issue will serve as a major aid in the 2013 RMC Update Exam. This exam will be accessible through the new learning platform called LearnerNation. You can learn more about this groundbreaking system by visiting www.learnernation.com.

3. Introducing Kathy DysonThe Medical Management Institute is very proud to introduce a new instructor to our team; Kathy Dyson. Ms. Dyson will play a huge role in content control, as well as in supporting you the student. Introduce yourself by emailing Kathy@dysoncs.com.

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