Peds KCuddy Final

8/8/2019 Peds KCuddy Final

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Kris Cuddy, CPC, CIMC

[email protected]

11/16/2009 - All Rights ReservedKCuddy


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` This presentation was current at the time it was printed or downloaded and isprepared as a tool to assist in coding and billing and is not intended to grantrights or impose obligations. Although every effort has been made to ensure theaccuracy of the information within these pages, the ultimate responsibility lieswith the user of this information. The author makes no representation, warranty,

or guarantee that this compilation is error free and will bear no responsibility orliability for the results or consequences of the use of this guide. This is a generalsummary that explains certain aspects of coding and billing, but is not a legaldocument.

` CPT is a current trademark of the American Medical Association.

` CPT is copyright 2010 American Medical Association. All Rights Reserved. Nofee schedules, basic units, relative values, or related listings are included inCPT. The AMA assumes no liability for the data contained herein. Applicable

FARS/DFARS restrictions apply to governmental use.` The International Classification of Diseases is based on the International

Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) aspublished by the AMA, copyright 2010 by Saunders, an imprint of Elsevier Inc.



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` Billing software

` EMR software

` Encounter forms

` Get updated coding books` Cheat sheets

` ABNs

` Forms for ordering labs, supplies, medications

` In-house policies containing CPT/ICD-9 codes` Print/save new NCDs, LCDs, local carrier coverage

decisions



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` Billing/coding staff

` Charge entry staff

` Providers

` Nurses

` M.A.s

` Referral Specialists

` Managers` IT department



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` Not everyone, meaning all carriers, will be on the

appropriate time-line for the changes

` You may receive inappropriate rejections due to

the carrier not having their systems updatedappropriately

` The first step when this occurs is to contact a

carrier representative prior to appealingThe carrier representative has a higher hand in dealingwith global issues such as these and may be able to get

the issue resolved much faster than appealing every

claim as they come in denied



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Became Effective October 1, 2009



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` 23 Deletions

` 312 Additions

` 45 Revisions

The majority of the additions were to E-codes



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239.8 274.0 279.4 348.8

453.8 488 768.7 779.3

784.5 799.2 969.0 969.7

E992 E993 E994 E995

E996 E998 V10.9 V53.5

V60.8 V72.6 V80.0



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` The CDC got rid of 488 and created two new

codes to better identify the flu outbreak last year1. 488.0 Influenza due to identified avian influenza

virus Avian influenza

Bird flu

Influenza A/H5N1



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2. 488.1 Influenza due to identified novel H1N1

influenza virus 2009 H1N1 [swine] influenza virus

Novel 2009 influenza H1N1

Novel H1N1 influenza

Novel influenza H1N1

Swine flu



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Congenital conditions:

`

756.72 Oomphalocele Exomphalos

x Congenital herniation of viscera into the base of the umbilical

cord

` 756.73 Gastroschisisx A congenital fissure in the anterior abdominal wall not

involving the umbilical cord; usually accompanied by

protrusion of viscera



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Perinatal conditions:

` 768.7X -Hypoxic-ischemic Encephalopathy (HIE)(generally permanent brain injury resulting from a lack of

oxygen or inadequate blood flow to the brain; infantsmay recover without sequelae (pathological disease)

768.70 HIE, unspecified

768.71 Mild HIE

768.72 Moderate HIE

768.73 Severe HIE



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` 779.3 went from four digits to five to better explainfeeding/stomach conditions in a newborn 28 daysold and under

779.31 Feeding problem in newbornx Slow feeding in newborn (excludes feeding problems in child

over 28 days old (783.3)

779.32 Bilious vomiting in newborn

x (excludes bilious vomiting in child over 28 days old (787.04)

x (vomit containing large amounts of bile suggestive of bowelobstruction distal to the papilla of Vater)



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779.3X Continued.

779.33 Other vomiting in newborn

x Regurgitation of food in newborn (excludes vomiting in child

over 28 days old (536.2, 787.01-787.04)

779.34 Failure to thrive in newborn

x Excludes failure to thrive in child over 28 days old (783.41)



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Voice, Speech, and Resonance conditions:

` 784.4X Received three additional codes to betterdescribe problems

784.42 Dysphonia

x

Hoarseness



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784.4X Continued

784.43 Hypernasality

x

Hypernasal speech is the sound of speech that results fromtoo much air escaping through the nose while talking

784.44 Hyponasality

x Hyponasal speech is the sound of speech that results from

too little air escaping through the nose (sounds like talking

with a stuffy nose)



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784.51 Dysarthria

x Excludes dysarthria due to late effect of cerebrovascular

accident (438.13)

x A disturbance of speech due to emotional stress, to brain

injury, or to paralysis, incoordination, or spasticity of the

muscles used for speaking

784.59 Other speech disturbance

x Dysphasia

x Slurred speech

x Speech disturbance, NOS



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Symptoms/Signs/Conditions that are ill-defined:` 787.04 Bilious emesis

Bilious vomiting (in patients older than 28 days of age (779.32)

` 789.7 Colic Colic, NOS Infantile colic Excludes colic in patients over 12 months old (789.0) and renal

colic (788.0)

` Now having colic as a diagnosis code eliminates the needfor using the excessive crying code in place of colic andmay give a valid reason for more frequent visits, anynecessary testing/diagnostics, and/or any necessary ordersof medication



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` 799.82 Apparent life threatening event in infant ALTE Apparent life threatening event in newborn and infant Use additional code(s) for associated signs and symptoms Excludes signs and symptoms associated with a confirmed

diagnosis code (code to the confirmed diagnosis)` Could necessitate critical care time or prolonged

services billing` Advise providers to note start and stop of face-to-face

time with patient when providing care for ALTE in the

office, and unit/floor time when in the hospital



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` An apparent life-threatening event, or ALTE, is also knownas a prolonged infant apnea spell. It is an episode in whichan infant has apnea, or stops breathing for a short time.The episode lasts long enough to cause: choking and gagging

color change in the skin and lips, first bright red then blue muscle weakness and limpness

` Babies sometimes breathe in cycles. In other words, theyalternate rapid breathing with slow breathing. This can benormal. However, apnea occurs when a baby has anepisode of not breathing at all that lasts for more than 20seconds.



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` During an ALTE, what happens in the body dependson the cause of the episode. A heart or lung problemcould cause an infant to temporarily stop breathing. Aslack of breathing continues, the infant may begin tostruggle for air, cough, and gag. Eventually, as theoxygen level in the blood decreases, the infant maybecome limp and pale, then may turn blue. ALTE canoccur both when an infant is asleep or when playingand active. Sometimes, simply touching the infant or

picking the infant up will make him/her begin breathingagain. In other cases, advanced medical support mayneed to be called in.



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` Viral infection, ie, respiratory synctial virus, aka RSV

` Bacterial infection, ie, pneumonia

` Food blocking the infant's airway, ie, food that was inhaled into the

windpipe

` An abnormally narrow airway cardiac arrhythmia` An abnormal heart rhythm

` Cardiomyopathy, which is an abnormal growth of the heart muscle

` Gastrointestinal conditions, such as GERD

` Respiratory conditions, ie, whooping cough

` Neurological disorders, ie, seizures, meningitis, or brain tumors

` Munchausen syndrome by proxy, a parenting disorder (when a parent

fabricates symptoms in the child)



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` In approximately 50% of ALTE cases, no cause is found.

` What happens after treatment depends on whether there is a cause.

An infant can often be sent home if no cause is found and the infant

appears healthy. Sometimes an underlying cause is treated with

concerns of more ALTE episodes. Then, the infant may need to stay

at a hospital to be monitored. Alternately, the infant may be senthome on an apnea monitor (a device with an alert if the infant stops

breathing). Treatment may be ongoing for causes determined to be

a disease or condition needing continuous follow-up or care. Also, it

may be helpful for a caregiver to receive training in CPR before

leaving the hospital.

` Monitoring can be done at home by the caregiver where an infant is

healthy and there is no further concern regarding the possibility of

more ALTE episodes.



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` 799.2X Received six additional codes to describe

more than just nervousness

` All of the following codes exclude anxiety (293.84,300.00-300.09) and depression (311) 799.21 Nervousness (nervous)

799.22 Irritability (irritable)

799.23 Impulsiveness (impulsive)

x Excludes impulsive neurosis (300.3)



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799.24 Emotional lability

x a condition of excessive emotionalreactions and frequent

mood changes, usually after brain injury, dementia with apsychosis of some sort, or Lou Gehrigs Disease

799.25 Demoralization and apathy

x Apathetic

799.29 Other signs and symptoms involving emotional

state



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Orthopedic Additions

` 813.4X received two additional codes to describe fracture

location 813.46 Torus fracture of ulna (alone)

x Excludes torus fracture of radius and ulna (813.47)

813.47 Torus fracture of radius and ulna

A torus fracture is a bone deformity in children in which the bonebends and buckles but does not fracture; it occurs commonly in theradius or ulna or both. This fracture occurs only in children becausetheir bones are softer than adults.



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` 832.X Received one additional code

832.2 Nursemaids elbow

x Subluxation of radial head

x This is a common event in toddlers and small children, often

accidental, caused by stress of traction on the forearm. The

child presents with an objective refusal to use the affected arm.

Treatment using a supination and flexion maneuver is oftensuccessful.



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` 969.0 Received eight new codes

` 969.0X Poisoning by antidepressantsx Use additional code to identify; drug dependence (304.0-

304.9) or nondependent abuse (305.0-305.9)

969.00 Antidepressant, unspecified

969.01 Monoamine oxidase inhibitors

x MAOI

969.02 Selective serotonin and norepinephrinereuptake inhibitors

x SSNRI antidepressants



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969.0X Continued

969.03 Selective serotonin reuptake inhibitorsx SSRI antidepressants

969.04 Tetracyclic antidepressants

969.05 Tricyclic antidepressants

969.09 Other antidepressants



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` 969.7 Received five new codes

` 969.0X Poisoning by psychostimulantsx All codes below exclude central appetite depressants (977.0)

969.70 Psychostimulant, unspecified 969.71 - Caffeine

969.72 Amphetamines

x Methamphetamines

969.73 - Methylphenidate 969.79 Other psychostimulants



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Sedation received one new code

` 995.24 Failed moderate sedation during

procedure Failed conscious sedation during procedure



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` V10.90 Personal history of unspecified malignantneoplasm Excludes V10.91

` V10.91 Personal history of malignantneuroendocrine tumor Code first any continuing functional activity, such as carcinoid

syndrome (259.2)

` V15.52 Personal history of traumatic brain injury Excludes V15.42

` V15.80 Personal history of failed moderate sedation

Personal history of failed conscious sedation



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` V15.83 Personal history of underimmunizationstatus Delinquent immunization status

Lapsed immunization schedule status

` V20.31 Health supervision for newborn under 8 daysold Health check for newborn under 8 days old

` V20.32 Health supervision for newborn 8 to 28 daysold Health check for newborn 8-28 days old

` V20.31 and V20.32 are for weight checks, skin checks, etc.



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` V60.81 Foster care (status)

` V60.89 Other specified housing or economic

circumstances

` V61.07 Family disruption due to death offamily member Excludes bereavement (V62.82)

` V61.08 Family disruption due to other

extended absence of family member Excludes family member in military deployment

(V61.01)



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` V61.23 Counseling for parent-biological child

problem

` V61.24 Counseling for parent-adopted childproblem

` V61.25 Counseling for parent (guardian)-foster

child problem

` V61.42 Substance abuse in family



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` V72.60 Laboratory examination, unspecified` V72.61 Antibody response examination

Immunity testing statusx Excludes encounter for allergy testing (V72.7)

` V72.62 Laboratory examination ordered as part of aroutine general medical examination Blood tests for routine physical examination

` V72.63 Pre-procedural laboratory examination Blood tests prior to treatment or procedure Pre-operative blood tests

` V72.69 Other laboratory examinationV72.6X is not to be used if any signs, symptoms, or

reason for test is documented



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` V80.01 Special screening for traumatic brain injury

` V80.09 Special screening for other neurological conditions

` V87.32 Contact with and (suspected) exposure to algae bloom

` V87.44 Personal history of inhaled steroid therapy

` V87.45 Personal history of systemic steroid therapy

Personal history of steroid therapy, NOS

` V87.46 Personal history of immunosuppressive therapy

Excludes personal history of steroid therapy (V87.44 and V87.45)



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New E codes to describe Activities

Categories E001 to E030 are provided for use toindicate the activity of the person seekinghealthcare for an injury or health condition, such

as a heart attack while shoveling snow, whichresulted from, or was contributed to, by theactivity.

These codes should be used in conjunction with

other external cause codes for external causestatus (E000) and place of occurrence (E849)



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Activities involving:

` E001 walking and running

` E002 water and water craft

` E003 ice and snow

` E004 climbing rappelling, and jumping off

` E005 dancing and other rhythmic movement

` E006 sports and athletics played individually

` E007 sports and athletics played as a team orgroup



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` E008 specified sports and athletics

` E009 cardiorespiratory exercise

` E010 muscle strengthening exercise

` E011 computer technology/electronic devices

` E012 arts and handcrafts

` E013 personal hygiene and householdmaintenance

` E014 person providing caregiving



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` E015 food preparation, cooking and grilling

` E016 land maintenance, building, andconstruction

` E017 roller coasters and other types of externalmotion

` E018 playing musical instrument

` E019 animal care

` E029 other activity` E030 Unspecified activity



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` E876 Other and unspecified misadventures

during medical care E876.5 performance of wrong operation (procedure) on

correct patient

E876.6 performance of operation (procedure) on

patient not scheduled for surgery (wrong patient)

E86.7 performance of correct operation (procedure) onwrong side or body part



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` E928.X has one new code E928.7 Environmental and accidental; Mechanism or

component of firearm and air gun

x Injury due to:

x Explosion of gun parts

x Recoil

x Pierced, cut, crushed, or pinched by slide trigger mechanism,

scope, or other gun part

x Powder burn from firearm or airgun

x Excludes accident caused by firearm and airgun missile (E922.0-

E922.9)



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` 008.65 Enteritis due to calicivirus

` 041.3 Klebsiella pneumoniae

` 041.86 Helicobacter pylori [H. pylori]

`

453.2 Other venous embolism and thrombosis ofinferior vena cava

` 453.40 Acute venous embolism and thrombosis ofunspecified deep vessels of lower extremity

` 453.41 Acute venous embolism and thrombosis of

deep vessels of proximal lower extremity` 453.42 Acute venous embolism and thrombosis of

deep vessels of distal lower extremity



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` 572.2 Hepatic encephalopathy

` 584.5 Acute kidney failure with lesion of tubular

necrosis

` 584.6 Acute kidney failure with lesion of renal cortical

necrosis

` 584.7 Acute kidney failure with lesion of renal

medullary [papillary] necrosis

` 584.8 Acute kidney failure with other specified

pathological lesion in kidney` 584.9 Acute kidney failure, unspecified

` 639.3 Kidney failure following abortion and ectopic and

molar pregnancies



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` 669.30 Acute kidney failure following labor and delivery,unspecified as to episode of care or not applicable

` 669.32 Acute kidney failure following labor and delivery,delivered, with mention of postpartum complication

` 669.34 Acute kidney failure following labor and delivery,postpartum condition or complication` 670.00 Major puerperal infection, unspecified, unspecified as to

episode of care or not applicable` 670.02 Major puerperal infection, unspecified, delivered, with

mention of postpartum complication

` 670.04 Major puerperal infection, unspecified, postpartumcondition or complication



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` 757.6 Specified congenital anomalies of breast

` 772.0 Fetal blood loss affecting newborn

` 776.9 Unspecified hematological disorderspecific to newborn

` 784.40 Voice and resonance disorder,unspecified

` 784.49 Other voice and resonance disorders



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` 793.0 Nonspecific (abnormal) findings on radiological andother examination of skull and head

` 793.1 Nonspecific (abnormal) findings on radiological andother examination of lung field

` 793.2 Nonspecific (abnormal) findings on radiological andother examination of other intrathoracic organs

` 793.3 Nonspecific (abnormal) findings on radiological andother examination of biliary tract

`

793.4 Nonspecific (abnormal) findings on radiological andother examination of gastrointestinal tract



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` 793.5 Nonspecific (abnormal) findings on radiological andother examination of genitourinary organs

` 793.6 Nonspecific (abnormal) findings on radiological andother examination of abdominal area, includingretroperitoneum

` 793.7 Nonspecific (abnormal) findings on radiological andother examination of musculoskeletal system` 793.89 Other (abnormal) findings on radiological

examination of breast` 793.99 Other nonspecific (abnormal) findings on

radiological and other examinations of body structure



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` 813.45 Torus fracture of radius (alone)` 996.43 Broken prosthetic joint implant` E876.5 Performance of wrong operation

(procedure) on correct patient`

V15.06 Allergy to insects and arachnids` V15.84 Personal history of contact with and

(suspected) exposure to asbestos` V15.85 Personal history of contact with and

(suspected) exposure to potentially hazardous body

fluids` V15.86 Personal history of contact with and

(suspected) exposure to lead



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` V57.3 Care involving speech-language therapy

` V61.29 Other parent-child problems

` V65.11 Pediatric pre-birth visit for expectant

parent(s)



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Becomes Effective January 1,

2010



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` More than 240 New CPT Codes

` More than 290 Changed CPT Codes

` More than 75 Deleted CPT Codes



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` For detailed in-person viewing, go to the following

appendices in CPT: Appendix B Summary of additions, deletions, and

revisions

Appendix M Summary of crosswalked deleted CPT

codes

x Bonus!! This goes back to 2007!

Appendix N Summary of resequenced CPT Codes



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` Resequencing is NEW! It is when a CPT code is moved into the appropriate

category but the CPT code itself did not change. The # sign is the symbol in front of the CPT code

advising resequencing of a code.

In the 2010 CPT, when you look where the code should

have been, a reference will direct you to the code range it

is in.



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` Well.for Medicare Part B beneficiaries, the

biggest change for providers is the elimination of

consult codes.` This is true when Medicare is primary or

secondary.

` Be sure your paper, e-encounters, and/or charts

have the most current insurance prior to thepatient seeing the provider!



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` Current CMS guidance advises your provider has the

following choices as of 1/1/2010: Office/Outpatient setting:

x Either New Patient E/M or Established Patient E/M

xFollow the New Patient rules to determine which one is appropriate

Facility (In-patient, SNF, AL):

x The admitting provider will bill for initial hospital care with a

modifier (AI was advised but this is NOT confirmed yet)

x The consulting provider will also bill for initial hospital care using

no modifier (99221-99223)CMS has implied a 6% office and 2% inpatient increase in fee

schedule for all E/Ms



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` CMS has advised there will probably be denials

and delays in payment

` CMS also advises that the requesting providershould still indicate they are requesting your

provider to see the patient CMS will probably want to see the documentation

verifying the request to see the patientx This appears to be true for office/out-patient/facility



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` The indication is for providers and coders to look

to the prolonged services codes and determine ifthey are appropriate additions to an E/M service.

` Prolonged service codes are often overlooked

` Opportunity to learn the codes



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` 99358, 99359 Prolonged physician service without

direct patient contact A prolonged service beyond usual non-face-to-face

component of physician time

Relates to a face-to-face service with the patient hasoccurred or will occur and relate to the ongoing

management. May be reported beginning 01/01/2010 on

separate date from E/M

Used only once per date Bundled by CMS and most carriers



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` 99358-99359 Should not be reported for time in

medical team conferences, on-line medical

evaluations, care plan oversight services,

anticoagulation management, or other non-face-

to-face services that have more specific codes

without upper time limits in the CPT.

` Again, CMS bundles this and so do most other

carriers



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` 99354-99357 have to be used with E/M codes` They must be used only with time-based E/M codes` These are the office based codes` An example would be if the provider performed the E/M

components of a 99213, but due to the patient having asthmadifficulty needed to give the patient multiple breathing treatmentsand medications and had to come in and out of the room to haveface-to-face monitoring and time with the patient over aprolonged period of time, his documentation reads he spent 1 hours face to face for the entire visit Take away the 15 minutes of 99213, leaving us with 1 hour and 15

minutes

99354 is for the first hour and we have 15 minutes left 99355 CAN be coded for the remaining 15 minutes



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` 99354-99355 Prolonged service in the office or

other outpatient setting requiring direct face-to-

face contact beyond the usual service;

` +99354 ; first hour List in addition to the E/M code

` +99355 ; each additional 30 minutes List in addition to 99354



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30-74 minutes= 99354 x1

75-104 minutes= 99354 x1 & 99355 x1

105 or more minutes (1 hr 45 min.) = 99354 x1 & 99355 x2

x Each additional 30 minutes after the 105 min.

= 1 more quantity of 99355



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` 99356-99357 Prolonged service in the inpatient

setting requiring direct unit/floor time beyond the

usual service;

` +99356 ; first hour List in addition to the E/M code

` +99357 ; each additional 30 minutes List in addition to 99354



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30-74 minutes= 99356 x1

75-104 minutes= 99356 x1 & 99357 x1

105 or more minutes (1 hr 45 min.) = 99356 x1 & 99357 x2

x Each additional 30 minutes after the 105 min.

= 1 more quantity of 99357



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` The language in the guidelines in the beginning of

E/M was changed to merge transfer of care into

concurrent care. CPT

reminded us that a transferof care is not a consult unless the transfer occurs

after the initial visit

` Payers other than Medicare Part B and Railroad

Medicare have not indicated they are making anychanges to billing consultation codes



70/79

` 99465 Delivery/birthing room resuscitation,

provision of positive pressure ventilation and/or

chest compressions in the presence of acute

inadequate ventilation and/or cardiac output. Revision

x (99465 may be used with 99460, 99468, 99477)

x 2009 CPT indicated Do not report with



71/79

` All carriers are only paying for administration because theimmunization itself is free

` Medicare Part B and Medicaid are recognizing G9141 -H1N1 administration, any route of administration, includingcounseling if provided

` Other carriers may be following AMA guidance to use90470 H1N1 administration, any route of administration,including counseling if provided

` 90470 was issued in September 2009 and is not in the2010 CPT book

` Recommendation is, if you do not already have this figuredout with your carriers, contact representatives and verifywhat code(s) they are accepting.



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` Three new codes

` Always done in a facility

` Includes moderate sedation

` The tests literally squeeze the life outof course

bringing it right back in

` Currently, there are 30 pediatric pulmonologists in

the United States who can perform these



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` 94011 Measurement of spirometric forced expiratoryflows in an infant or child through 2 years of age

` 94012 Measurement of spirometric forced flows,before and after bronchodilator, in an infant or childthrough 2 years of age

` 94013 Measurement of lung volumes (ie, functionalresidual capacity (FRC), forced vital capacity (FVC),and expiratory reserve volume (ERV), in an infant orchild through 2 years of age.

` 94013 can be done twice (eg, before and after

bronchodilator) and, if this occurs, report 2 units

11/16/2009 - All Rights Reserved

KCuddy


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` 01632 has been deleted due to low reporting

volumes, look at:

` 01630 Anesthesia for open or surgicalarthroscopic procedures on humeral head and

neck, sternoclavicular joint, acromioclavicular joint,

and shoulder joint; not otherwise specified

` 01638 - ;total shoulder replacement


KCuddy


75/79

` Revisions to musculoskeletal were extensive with a

goal of making it a smoother process to code using

the depth and size of lesions, as well as soft tissue

and bone tumor codes

` Notable digestive system changes are in the anussection relating to editorial and resequencing

` Paravertebral facet joint or facet joint nerve injection

codes were deleted and a new subheading added for

paravertebral spinal nerves and branches with 6 newcodes (all indicating imaging guidance (CT or fluoro) is

included.


KCuddy


76/79

` The provider should define the size of the lesion

and the size of the excision in order for coding to

be appropriate.` If coding sizes by the path report, revenue will be

lost because lesions shrink after removed and

again after being put into the liquid of the

pathology container (usually a percentage offormalin)


KCuddy


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KCuddy

Questions?


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` CPT 2010, Professional Edition, AMA

` ICD-9-CM 2010, Professional Edition, AMA

` AMA CPT and RBVRS 2010 Annual Symposium Information

` AMA CPT Changes 2010 An Insiders View

` http://www.healthopedia.com/apparent-life-threatening-event/, 11/17/09

` http://www.medilexicon.com/medicaldictionary.php, 11/17/09

` http://www.cms.hhs.gov/icd9ProviderDiagnosticCodes/07_summarytables.asp, 11/17/09

` http://www.michigan.gov/mdch/0,1607,7-132-2945_42542_42543_42546-153200--,00.html, 11/17/09

` http://www.wpsic.com/medicare/part_b/index.shtml , 11/17/09

` www.cms.hhs.gov/MLNMattersArticles/downloads/se0920.pdf, 11/17/09

` http://www.msv.org/MainMenuCategories/MemberCenter/PressRoom/News/Billing-H1N1-vaccine-at-001-for-UnitedHealthcare.aspx , 11/17/09

` http://www.cdc.gov/h1n1flu/vaccination/pdf/List_of_Annotated_CMS_Links_102609_rev.pdf, 11/17/09

` http://www.searchmedica.com/search.html?q=CPT&useraction=search&ss=defLink&fr=true&c=pm, 11/15/09


KCuddy


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Thank You!

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