Diagnosis Assignment Sequencing and Coding for

Long Term Care

Presented by:

Lizeth Flores, RHIT, RAC-CT

Anderson Health Information Systems, Inc.940 W. 17th Street, Suite B

Santa Ana, California, 92706Tel. (714) 558-3887

Email: lizeth@ahis.net

Objectives • Participants will:

– Correctly identify primary / Secondary diagnoses

– Correctly assign ICD-9-CM codes to diagnoses

– Correctly sequence diagnoses for coding assignment

Purpose of ICD-9-CM Coding

• Statistical Data • Billing and reimbursement • Compliance with Federal Reporting

Standards / HIPAA • Provide data into the types of Residents and

conditions treated

• ICD-9-CM Official Guidelines for Coding and Reporting

• HIPAA • www.cdc.gov/nchs/icd.htm

Requirements

• Official coding guidelines require the use of V codes for aftercare and specify that applicable aftercare V-codes are to be used for conditions requiring continued / long term care or healing phase of a condition/disease.

• The official coding guidelines are developed by CMS (Centers for Medicare and Medicaid Services) & NCHS (National Center for Health Statistics) and updated in October and April of every year. http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf

Requirements• Per ICD-9-CM Official Guidelines for Coding

and Reporting, aftercare codes are generally first to explain the specific reason for the encounter (admission)

• Certain aftercare code categories need a secondary dx code to describe the resolving condition or sequelae

• For others (V codes) the condition is inherent in code title

• The FI will not accept V-codes as principal diagnosis - is an INCORRECT statement.

• The Principal DX must be reported according to Official ICD-9-CM guidelines for coding and reporting, as required by HIPAA including any applicable guidelines regarding the use of V-Codes

Not So New

Coding clinic Fourth Quarter 1999• Published rules for the use of V codes• Addressed the use of V codes in LTC settings • Coding clinic Fourth Quarter 2003• Clarified the use of aftercare V codes for all

subsequent encounters after the initial treatment for a fracture

• “for statistical purposes, a facture should only be reported once”

CMS Manual System Transmittal 437

• Principal Diagnosis Code - SNFs enter the ICD-9-CM code for the principal diagnosis in FL 67. The code must be reported according to Official ICD-9-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-9-CM diagnosis code, including all five digits where applicable.

• Other Diagnosis Codes Required – The SNF enters the full ICD-9-CM codes for up to eight additional conditions in FLs 68-75. Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-9-CM guidelines.

Medicare Claims Processing Manual 100-04

Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing

http://www.cms.gov/manuals/downloads/clm104c06.pdf

30 - Billing SNF PPS Services (Rev. 2011, Issued: 07-30-10, Effective: 01-01-11,

Implementation: 01-03-11)

• Principal Diagnosis Code - SNFs enter the ICD-CM code for the principal diagnosis in the appropriate form locator. The code must be reported according to Official ICD-CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes. The code must be the full ICD-CM diagnosis code, including all five digits where applicable.

• Other Diagnosis Codes Required – The SNF enters the full ICD-CM codes for up to eight additional conditions in the appropriate form locator. Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those contained in the ICD-CM guidelines.

What if…..• Could the facility face claim denials due to

this change?

• NO – the FI is well aware of the ICD-9-CM coding guidelines and requirements.

Ready ……..Set…….Go

Definition of Principal Diagnosis

• “FIRST LISTED DIAGNOSES” is the diagnosis that is chiefly responsible for the admissions to, continued residence in the nursing facility and the diagnosis that support the reimbursement and should be sequenced first.”

• Medicare – To be covered the extended services must be for the treatment of a condition for which the resident received inpatient hospital services during the 3-day qualifying stay

V Codes as principal diagnosis

• V Codes may be listed as a principal or secondary diagnosis as stated in official coding guidelines

• V Codes are used in both inpatient and outpatient setting

• V Codes indicate a reason for an encounter

Type of Codes used in LTC

• Aftercare – used when the initial treatment of a disease or injury has been performed and the patients still requires continued care to heal or recover.

• Late Effects – a late effect is a residual condition that remains and requires medical evaluation, rehab treatments and/or nursing care after the initial illness or injury.

Type of Codes…………

• History of – (Hx) – history codes are acceptable on any Medical record regardless of reason for admission/encounter.

• A history code is distinct from a “status” code in that history codes indicate that the patient no longer has the condition and “status” codes indicated a present state.

Practice #1

Chose from the following and assign the

Correct category:

• After Care

• Late Effect

• Chronic Condition

• Acute Condition

Practice #1 (cont.)

• Hemiplegia following due to recent CVA

• Total Hip Replacement

• Acute UTI treated with Cipro.

• Dementia

• Late Effect

• After Care

• Acute Condition

• Chronic Condition

What to Code?

ALL CONDITIONS THAT EXIST AT THE TIME OF ADMISSION, THAT EFFECT

TREATMENT RECEIVED

DO NOT CODE

• DIAGNOSES THAT DO NOT AFFECT TREATMENT OR LENGTH OF STAY

• WHEN CONDITION NO LONGER EXISTS• DO NOT ASSIGN PROCEDURE CODES• Examples: Fractured forearm 6 years ago,

pneumonia, UTI that were resolved (these will only be coded if the Resident is admitted with Antibiotics)

Locating the Principal Diagnosis

Section II. Selection of Principal Diagnosis

• The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

• For SNF reason for admission to the facility

EXAMPLES

1. Resident was treated for UTI at the hospital and is still on IV antibiotic therapy.

2. Resident had surgery for a bowel obstruction and needs care to the surgical site and physical / occupational therapy

• 1. UTI can be the primary diagnosis since Resident is still receiving ATB therapy

• 2. First listed diagnosis would be admission for multiple therapies and secondary diagnosis aftercare following surgery to the digestive system.

Admissions/Encounters for Rehabilitation

• When the purpose for the admission/encounter is rehabilitation, sequence the appropriate V code from category V57, Care involving use of rehabilitation procedures, as the principal/first-listed diagnosis. The code for the condition for which the service is being performed should be reported as an additional diagnosis.

V57 – Care Involving Rehab

• Category V57 does not indicate that rehab services were provided, only that the resident was admitted for this purpose

• Only one code from category V57 is required. Code V57.89, Other specified rehabilitation procedures, should be assigned if more than one type of rehabilitation is performed during a single encounter. A procedure code should be reported to identify each type of rehabilitation therapy actually performed

V57 Care Involving Rehab

• Code also the condition requiring the rehab, such as:

– Residuals

– Late effects

– Aftercare

– symptoms

Choose the Principal Diagnosis

• Fall 3 months ago

• Chronic kidney disease

• Above the knee amputation Rt. Leg (10 days ago)

• Anemia

• MRSA of surgical wound (resolved)

Where are the diagnoses???

• Transfer Records

• History & Physical

• Progress Notes

• Admission Orders

• Discharge summary

• Transfer documentation

• Surgical reports

• Consultations

• Physician Progress notes

• Lab reports and radiological studies

Diagnosis Sequencing

• The order in which codes are listed is called sequencing.

• Every effort should be made to record the codes in a logical sequence that is descriptive of the resident’s condition.

Secondary Diagnoses

– May have multiple secondary codes– List and code conditions related to

therapy and services provided– Review and update as condition

changes – sequence may change over time

– Billing staff should work with Nursing and Health Information Department to know which diagnoses are current, which is principal, etc.

Secondary Diagnoses

• Order by complexity.• Assign the condition with the higher

complexity first. (those that require the most resources i.e. wound care vs. hypertension)

• All conditions present at the time of admission, and that affect the treatment provided and length of stay should be coded.

Choose the correct sequence

• Diabetes

• Fx left forearm due to fall last week

• UTI (on antibiotics)

• Hyperlipidemia

Acute Diagnoses

• Acute dx treated in the hospital should be coded until the condition is resolved, after the resident is transferred to the SNF

• Examples:

MRSA

Pneumonia

UTI

CVA

V-Codes

• V-codes are assigned to problems that affect the patient’s health but are not in themselves a current illness or injury

• V-codes can be used to represent status or history. • Examples:

– Status Cardiac Pacemaker V45.01– Status heart valve prosthesis V43.3– History of falls V15.88– CABG V45.81

• Remember not to use acute care codes when coding aftercare

• Aftercare are used when the initial treatment has been performed but the patient continues to need care during the healing / recovery phase

• Examples: • Aftercare following surgery • Physical and/or occupational therapy • Aftercare for healing traumatic fracture

Let’s Practice

• Admitted for physical therapy, status post total knee replacement due to arthritis

1) Admission – rehabilitation – physical

2 ) Aftercare – following surgery for – joint replacement

3) Replacement – joint – Knee

V57.1, V54.81 , V43.65

• Post hysterectomy for uterine cancer three years ago (no further treatment)

• History – personal – malignant neoplasm – uterus

• V10.42

Assigning Code Numbers

• Both the Alphabetic Index and the Tabular List must be used when locating and assigning a code.

• Do not rely on just one since this can lead to errors in code assignment and a less specific code selection

How to Select Codes

• Locate each main term and subterm in the alphabetical index, i.e., Chronic Kidney Disease Disease

1. Disease 2. Kidney 3. Chronic

• Verify the code selected in the Tabular list

• Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List

Code to the Highest Level of Specificity

• Assign 3 digit codes only if there are no four digit codes within the category.– There are only 100 codes with

only 3 digits• Assign 4 digit codes only if there is no

fifth digit.• Assign 5 digit codes when indicated.• Samples – 486, 401.x, 250.xx

Let’s Practice

• Scabies

• Colitis

• Hypertension

• Benign prostatic hypertrophy (BPH)

• Scabies - 133.0

• Colitis – 558.9

• Hypertension – 401.9

• Benign Prostate Hypertrophy 600.00

To “V” or not to “V”Scenario # 1

• A resident is admitted for physical therapy following a hip replacement for an right hip fracture due to a fall.

To ‘V’ or Not to ‘V’: Scenario #1

• Physical therapy:• V57.1 Physical Therapy

• Intertrochantic right hip fracture due to a fall:• V54.13 Aftercare following traumatic hip

fracture

• Hip replacement:• V54.81 Aftercare following joint

replacement• V43.64 Joint replacement, hip

To ‘V’ or Not to ‘V’: Scenario #2

• A resident is admitted for P.T. & O.T.following a hip fracture after a fall.The physician indicated that the fracture was due to osteoporosis. The Discharge Summary stated that old compression fractures of the vertebrae due to osteoporosis were present on x-ray.

To ‘V’ or Not to ‘V’: Scenario #2

• Physical Therapy and Occupational Therapy

• V57.89 Multiple therapies• Hip Fracture (due to osteoporosis)

• V54.23 Aftercare for continuing treatment of healing pathologic fracture of hip

• Osteoporosis• 733.00 Osteoporosis

• Compression fractures of vertebrae• 733.13 Pathologic fractures of

vertebrae

Combination Codes

• A single code used to classify TWO (2) diagnoses or a diagnosis with an associated manifestation or complication.

• Key words:

– “AND”, “AND/OR”– “WITH”, “WITH MENTION OF” OR

“ASSOCIATED WITH”– “EXCLUDES”

Combination Codes

• Single codes used to classify two diagnosis or a diagnosis with a manifestation

• Example:

• Candidiasis with meningitis 112.83

Let’s Practice

• 1. Chronic Peptic Ulcer with Hemorrhage

• 2. Cerebral thrombosis with cerebral infarction

• 3. Diverticulitis of Duodenum “with” bleeding

Manifestation Codes

• There are written instructions in ICD-9-CM coding books for sequencing codes.

• The underlying Dx (cause/s) coded first, followed by codes for manifestations.

Manifestation Codes

• Diabetic Neuropathy • Diabetes with neurological manifestations

must be coded first (250.60) • The tabular list will guide you to “Use

additional code to identify manifestation, as:” • Polyneuropathy in diabetes (357.2) • The tabular section will tell you that this code

is not allowed as a principal Dx and will guide you to code underlying disease, as (Diabetes with complication…)

Combination Codes

• Etiology codes – USE ADDITIONAL CODE

• Manifestation codes – CODE 1st Underlying Dx.

• Codes in parentheses identify conditions that require multiple coding. Also, codes in parentheses CAN NOT be sequenced as PRINCIPAL Dx.

Combination Codes

• Anosmia following CVA

• 438.6, 781.1

• “with”, “with mention of”, or “associated with” – this code can only be used if both conditions are present

• Kidney Infection …..590.9

with Calculus 592.0

Slanted Brackets [ ]

• Indicate proper sequencing for the two codes listed.– The code number before the

bracket is coded first.– The code number inside the

brackets is coded second.Codes in brackets in the alphabetic

index can NEVER be sequenced as the principal diagnosis.

EXAMPLES

1.Arthritis, arthritic --- due to or associated with hypothyroidism

244.9 [713.0]

Example

• 1. ALZHEIMER’S DEMENTIA

• 2. DIABETIC GLAUCOMA

Multiple Coding

• Examples:

– Aftercare following kidney transplant – V58.44 (aftercare involving organ

transplant), – V42.0 (Organ/tissue replacement by

transplant , kidney)– Aftercare following arteriocoronary bypass – V58.73 (aftercare following surgery of the

circulatory system), – V45.81(aortocoronary bypass status)

use aftercare codes to provide better detail

Sequencing Multiple Codes

• “Using Additional Codes”

– When the instructions say “Use additional code….” the additional code is sequences second.

Example

UTI due to E.coli

599.0, [041.4]

Let’s Practice

• 1. Chronic Peptic Ulcer with Hemorrhage

• 2. Cerebral thrombosis with cerebral infarction

• 3. Diverticulitis of Duodenum “with” bleeding

“Exclusions”

Let’s have a look:

• See 429 section

• Under Cardiovascular Disease, Unspecified

• Excludes: That due to hypertension

Coding Diabetes

• Metabolic manifestations of the disease – require only one code

– Example:

• Diabetes with ketoacidosis 250.1x

Combination Codes

• Some Diabetic Conditions Require 2 Codes

– “Diabetic” or “Due to”

• One Code for Cause• One Code for Complication

– Always sequence cause before complication

Combination Codes

• Example:

– Diabetic foot ulcer

• Diabetes with other manifestation

–250.8x

• Ulcer of lower limb, except decubitus

–707.1x

Skin Ulcers

• Clarification of clinical terms related to skin ulcers www.cms.hhs.gov/manuals/pm trans/r4som.pdf

• Pressure Ulcer is a synonym for decubitus ulcer – due to prolonged pressure

• Subcategory 707.0x has fifth digits to identify site

2009- New- additional code must be used to identify stage

Skin Ulcers of the Lower Limbs

• Non pressure ulcers of lower leg• Fifth digits to identify site• Multiple coding, code first the

underlying dx, such as arteriosclerosis, diabetes, venous hypertension

– i.e. diabetic ulcer of left fifth toe 250.80, 707.15

Stasis Ulcers

• The most common type of vascular ulcers

– In Alphabetical index under “ulcer” , the index lists “venous” as a non-essential modifier under the subterm “stasis” that refers to code 459.81.

– Under section 459.81 in the Tabular List you will be instructed to code any associated ulceration from category 707.0-707.9

Reporting Same Diagnosis Code More than Once

• Each unique ICD-9-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions or two different conditions classified to the same ICD-9-CM diagnosis code.

Pressure Ulcer

• Use add’l code to identify pressure ulcer stage

• 707.20 pressure ulcer, unspecified stage• 707.21 pressure ulcer, stage I• 707.22 pressure ulcer, stage II• 707.23 pressure ulcer, stage III• 707.24 pressure ulcer, stage IV• 707.25 pressure ulcer, unstageable

Bilateral pressure ulcers with different stages

• When a patient has bilateral pressure ulcers at the same site (e.g., both buttocks) and each pressure ulcer is documented as being at a different stage, assign one code for the site and the appropriate codes for the pressure ulcer stage.ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2010 Page 50 of 105

Myocardial Infarction

• A code from category 410.XX must be assigned if the admission is strictly for rehabilitation within eight weeks of the acute MI.

• The fifth digit 2 would be used in LTC to designate observation, treatment or evaluation of MI within eight weeks of onset, following the acute phase or in the healing state.

Myocardial Infarction

• If the admission takes place after eight weeks assign code (412) Old Myocardial Infarction

Neoplasms with Metastasis

• Two codes

– One for primary (original site)

– One for each secondary site• Please be as specific as possible

when listing the diagnoses

Unknown Secondary Sites

• Ex: Cancer of Lower lobe of lung with metastases (162.5, 199.0)

• Primary site will be coded first

• An code for Unknown secondary site will be assigned to the metastasis

Unknown Primary Site

• The site of the metastasis will be sequenced first

• The unknown primary site will be assigned an “unknown site” code and sequenced after secondary site(s)

• Ex: abdominal metastasis from unknown origin (198.89, 199.1)

• Unknown primary would not be used as principle diagnosis in SNF

• The metastatic site is coded first

V-Codes for Neoplasms

• Primary site must still be identified• If removed, eradicated no longer

under treatment• Use a personal history V-code,

History,site, malignant neoplasm

• Using this V-code will identify primary site responsible for metastasis that is no longer present

V-Codes for Neoplasms

• Do not use codes from category V10 for secondary metastatic sites removed or not

• ICD-9-CM does not provide code numbers for “history of secondary neoplasm site

V-Codes for Neoplasms

• A primary malignancy

– Previously excised or eradicated from its site

– And there is no further tx directed to that site

– And there is no evidence of any existing primary malignancy,

– A code from Category V10 is used to identify the former site of malignancy

V-Codes for Neoplasms

• V12.41 Personal history of benign neoplasm of the brain.

– Previously, no code to indicate that the patient had benign growth. These can cause serious symptoms in the patient.

V58.42 Neoplasm

• Official coding guidelines for neoplasm apply when using the aftercare following surgery for neoplasm V58.42

• Aftercare code V58.42 may be used with either the current neoplasm code or a code from category V10, whichever is applicable

Code It

• History of breast cancer with metastasis to the lung

• Carcinoma of prostate with metastasis to spine

• Basal cell carcinoma of chest

• Hypothyroidism due to history of thyroid cancer (thyroid removed)

Late Effects of CVA (438.0-438.9)

• Rather than code the residual condition AND the late effect, combination codes that include the late effect should be used. Additionally, these can be used with a new CVA.

• DO NOT code 436 for CVA codes from categories 430-436 are used for the initial episode of care for an acute CVA at the hospital

Late Effects…..

• The residual condition is coded first and the late effect is sequenced second

• Multiple coding is required for most late effects

• A late effect is not used as a principal dx, except for Category 438 Late Effect of CVA

– i.e. Left Hemiplegia due to CVA 438.20

438 Late Effects of CVA

• Official coding guidelines state that Category 438 is used for admission and encounter for post acute care following treatment of the CVA in the acute hospital

• Codes from categories 430 to 436 are reserved for the “initial” (first) episode of care for an acute CVA that was provided in the qualifying hospital stay and should not be used in SNF

438 Combination / Multiple Coding

• Category 438 includes combination codes that describe both the cause and the residual deficit

• Right hemiplegia due to old CVA 438.20• More than one code my be used from

category 438 to identify multiple residuals from a CVA

• Dysphagia and left hemiplegia post CVA 438.82, 438.20

438

• Use additional codes with category 438 if the combination code does not address all elements of diagnostic statement

• Multiple coding is used to identify residuals of CVA that do not have a specific code

• Seizure disorder following CVA 438.89, 780.39

Aftercare for Healing Traumatic Fracture

• For residents admitted to a SNF for care following treatment in the acute hospital for a traumatic fx use the aftercare codes from Subcategory V54.1

• Coding Guidelines require an aftercare code be used after the initial encounter for care of a fx.

V54.1 Aftercare for healing traumatic fracture

• For statistical purposes, a fracture should only be coded once. If the same fx is coded for all encounters, it makes collection of fracture statistics difficult

• The V54.1 identifies the site of the fracture and that it is in the healing phases

• Aftercare for Fractures; Pathologic and Traumatic

V54.1 Aftercare for healing traumatic fracture

• The fifth digits identify the specific site of the healing fracture

• The fifth digit 9 is used for other specified sites

• If there are several bones that would be classified to the other specified site, only one code is used

V54.1 Aftercare for healing traumatic fracture

• DO NOT code V58.43 Aftercare following surgery for injury and trauma (conditions classifiable to 800-999) Exclusion note states “Excludes: aftercare for healing traumatic fracture”

• Remember to always refer to the tabular list and carefully read the instructions and exclusions.

Aftercare for Healing Pathological Fracture

• To assist in accurate coding assignment; as much as possible, be specific as to the

nature of the fracture

• Traumatic vs. Pathological

Joint Replacement

• Joint replacement of knee for osteoarthritis (V58.78), V54.81, V43.65

• Coding guidelines direct not to code the disease condition that was treated with the surgery

Aftercare Following Surgery

• The acute dx for which the surgery was performed is not reported for aftercare encounters or admissions but can be listed as a secondary diagnosis in order to link the LTC services to the qualifying stay and as further explanation of the after care code.

• Use other aftercare or symptom codes to provide better detail

• Note the instructions with each code that identifies the range of conditions that are included in the aftercare code number– i.e. aftercare post cataract extraction with

lens implant: V58.71, V45.61, V43.1

Heart Conditions due to HTN

• When there is a casual relationship is states as “hypertensive” or “due to hypertension” heart conditions are assigned by Category 402 Hypertensive Heart Disease

• Arteriosclerotic disease due to hypertension 402.90

Circulatory System

• Let’s Code

1. Chronic hypertensive kidney disease

2. Deep vein thrombosis patient on Coumadin

Respiratory System

• Let’s Code

• Aspiration Pneumonia

• Chronic bronchitis with emphysema

Guidelines: the coder should make every effort to record the codes in logical sequence that is descriptive of the patient’s condition

AUDITS

Medicare

Cert / Re-Cert

ADMISSION

DISCHARGE

CHANGE OF CONDITION

HIPAA

5010

ASC X12 Technical Reports Type 3, Version 005010

• Final Rule to change from current version X12 Version 4010/4010A1 was published January 16, 2009

• 5010 Compliance Date

Sunday January 1, 2012

Electronic Data Interchange (EDI) The next level

• Implementation of HIPAA Version 5010 Presents

• Changes to software, systems and billing procedures.

• Substantial changes in the content of the data that providers submit with their claims, as well as the data available to them in response to their electronic inquiries for eligibility or claims status.

ICD-10-CM

• Accommodates the use of ICD-10-CM

– Distinguishes between principal diagnosis, admitting diagnosis, external cause of injury and patient reason for visit codes.

This is not currently supported by version 4010/4010A1

Important Dates

• Level I* compliance to begin by:                      

 December 31, 2010• Level II** Compliance

by:                                 

December 31, 2011• All covered entities have to be fully

compliant on:     

January 1, 2012

Level I Compliance

• Level I compliance means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing."  We expect covered entities to be testing throughout calendar year 2011, and to schedule testing as early as possible, to ensure sufficient time for corrective actions and re-testing.

Level II Compliance

• Level II compliance means "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards."

What you need to do…….

• Communicate with your vendors

– Discuss software updates and system requirements for transitioning to Version 5010

– Will updates be made with enough time to allow for testing while continuing to use Version 4010A1

– Discuss any cost involved with this transition

• Communicate with MACs and any other payers or billing services

– Learn about their testing and implementation plans and requirements

– Learn about any fee changes resulting from this transition (if any)

• Identify possible changes to your current workflow, policies and procedures

• Identify staff training needs

• Identify key staff and define roles to ensure an efficient transition

• Test with your vendors

• Be aware of testing dates

• Don’t wait until the last minute allow yourself enough time to correct errors and ensure compliance by 1/1/12

Questions for discussion

Thanks for attending