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0:02 Everyone, and welcome to Roundtable 143.
0:05 For the second consecutive session, we have a record number record number of registrants.
0:13 So once again, kudos to you guys for getting year 20, 22 coding Education, off on the right foot.
0:20 My name is Scott Memtec, VP of Coding, Education, and Continuous Improvement.
0:24 First of all, X is a term division, and it’s my pleasure to introduce, as always, today’s speaker, Janice Janice’s, our Director, This Education, so reviewing programmatic ICD 10 PCS concepts, and providing advice on how to convert them. So I’m looking for this one quite a bit.
0:43 Some housekeeping, and in light of the increasing attendee count. There are no call in numbers, the format is streaming only.
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2:26 All right, that’s it. So I’m Janice.
2:29 Thank you, Scott. Thank you, everyone, for attending today. And I just wanna make a note that all of those links that Scott mentioned are at the end of the presentation. So they are there for reference in the download, and also in the e-mail. The follow up e-mail. You’ll get a link to download the presentation. If you can’t download it now, But that is in the handout section, as Scott mentioned. So let’s get started first. I am going to start with an in the News topic, this is kind of making the rounds. I think a lot of people have seen this, so we’re gonna start start about in the news, the new spinal cord stimulation study that puts people with paralysis on their feet. Again, we’ll start out with that. Not that that’s very problematic at this point, because it’s still in clinical trials. But I did want to talk about that.
3:13 We have endoscopic G G J bypass, or pulmonary artery dilation or supplement procedures … within searches aren’t Watchman device. And this, I mean, we’re going to talk to be talking about these specific scenarios, but they apply to any coding that we’re doing so well. We’ll talk. We’ll go through those as we talk through the presentation. But those are some interesting things that came up as we’re coding some of these these procedures.
3:39 So let’s get started with our in the news segment.
3:49 On our new spinal cord stimulation. Now, the codes that we, that I’m going to provide in this webinar, just as kind of a practice, or have very theoretical, because we don’t, I don’t have an op report, I’m basing it on information that’s in a article and also on the US. Clinical trial page, so I don’t know if these codes are 100% accurate. I don’t know if they’re going to create new technology codes for this? So these are for PCS codes. These are theoretical codes, based on what’s provided, the limited information that was provided.
4:22 Um, in the News article slash the US clinical trial information. So if you haven’t heard the news, I did put a link to the article. If you want to read more about it. We’re gonna kind of talk about the high level bullet points here, but there is an ongoing clinical trial called the … trial. It’s a Swiss based trial.
4:42 They do have ongoing studies in the US. In conjunction with the Swiss Study, Um, it’s called the Epidural. Electrical stimulation. S with robotic assisted rehab and Patients with Spinal cord injury and what what happens here is that they insert a 16 electro device. It’s implanted in the epidural space so We’re gonna have to know that they implanted in the epidural space in order to assign the correct code if you’re used. If you’re used to coding or nerve stimulator codes for PCS, an area between the vertebrae in the spinal cord membrane, and then the electrodes receive currents from a pacemaker implanted under the skin of the abdomen, so they say abdomen. I don’t know based on my research. It’s it’s it’s typically implanted in the Botox area. I don’t know, maybe in this, in this trial, they planted in the abdomen. I’m not 100% certain on that, I’m just basing it on what was reported in the article.
5:37 So, when the devices are in place, the researchers can use a tablet or computer to initiate unique sequences of electrical pulses sent to these electoral, epidural electrodes via the pacemaker and they typically we typically see that now to with for nerve nerve pain relief, typically, that’s what we see, our neuro stimulators in this setting being used for. We also have some other situations where we at patients have neuro stimulators.
6:04 So, they’re looking into this electrical stimulation. It’s actually been decades, so at least 30 years. They’ve been looking into this electrical stimulation and what can what it can be used for?
6:13 So we know we have it for pain control and things like that, And they’ve had some success in the past, but it requires a lot of rehab. But this study showed that the patients were able to move. They were completely paralyzed and they could have some sensation. It can walk again, almost immediately.
6:36 Obviously, they have to be stimulated in order for them to be able to walk. They, again, they’ve had studies before, that, they’ve had to have several months of rehab to kind of get things going.
6:47 But in this study, they found that, based on this specific type of stimulation, they could, they were able to bear their body weight and walk almost immediately. So, they can regain voluntary control of their legs during the stimulation.
7:06 And, you know, they talk about that. And it’s pretty cool. It’s amazing. I know we’re talking about it as a group.
7:14 And they stated in the in the article that it may be 3 to 4 years before this comes to, like, no, it’s applied to more people, and it becomes mainstream.
7:25 But just something to be on the lookout for, I don’t know if any of any of you on this call have been involved in the clinical trials, but there are some clinical trials going on for this study.
7:38 So what I was able to find out was, Oops, I skipped a slide here.
7:46 Here’s a link to the US Clinical Trial. They’re using an active RC that is a rechargeable device. It’s a multi re leader port device, and there are either using a 565 liter goto lead in the Epidural space. So based on this information, I kind of surmised what the code is going to be for this. So O J H.
8:06 They did say abdomen in the article. So I’m assuming it’s the abdomen. We actually have other options, you know, chest things like that.
8:13 So this made this body part may change, but our device, we have our single generator or single array single array rechargeable, multiple marae, multiple array rechargeable, and we just have a simple stimulator generator. And again, this is theoretical because technically they could be creating a new technology code for this type of stimulation or simulation, I’m not 100% sure at this point. I didn’t see anything specific and correct me if I’m if anyone has seen any information, let me know.
8:44 I haven’t seen anything any talk about new codes for this yet.
8:50 But then also we have the insertion of the pacemaker device and then we have insertion of the leads and in that article they did talk about the body part being. Not specifically implanted in the spinal cord, but the epidural space. So Epidural space will coach is spinal canal as our body part and then the approach I’m assuming. They did say in most cases They’re implanted, percutaneous lee. There are, maybe some cases where they have to do an alum enacted me to place them, but in most cases, it’s going to be percutaneous and then our device. It’s going to be nerve stimulator Lead.
9:26 So just to kind of give you a, kind of give you a, taste, of that, again, theoretical.
9:35 On on, on that situation, So just something to keep in mind as this comes to fruition is I think this is going to create a lot of good quality of life for a lot of people if this is successful, so.
9:50 And some more information about you know what is a single versus multiple array generator? This is from the Medtronic website. The link is actually here in the slide. I just copied and pasted it from the slide here. It is from 20 12, but they talk about the difference between a single array generator. It has one port that can be connected to one lead, and a multi array generator has 1 or 2 or more ports that can be connected to two or more leads.
10:15 So some more information and again, this isn’t exactly the exact exact picture I was able to find and it’s a picture of an insertion of a lead in an Epidural space. You can kind of see what it looks like.
10:27 And I didn’t I don’t think they document it where they exactly implant the leads or anything like that. This is just a picture. This is, you know, talking about where the weeds can be inserted. It depends on, I guess it depends on the area paralysis.
10:44 I didn’t find that information, but we don’t have to worry about the specific site or if we go back to the codes, We just have neuro Stimulator Lead. It doesn’t say where, and maybe that’ll change, right? Maybe that’ll change.
10:58 Once we have newer codes, perhaps, I don’t know if we’re going to have newer codes for this. It’s already using technology that we already have in place, So maybe, maybe not.
11:11 So moving on to our main topic is our kind of some of the issues that I see coders making when deciding on a procedure code. So let’s take a look at endoscopic gastro, … or bypass.
11:25 It’s somewhat of a newer, a newer code.
11:28 I mean, technology, I guess, you could say, it’s not new technology. But a newer approach to doing bypass procedures, or Gastro, J, general bypass, let me know in the comments if it’s something that you’ve seen.
11:42 So first, I want to start with a case summary. So, this patient was admitted for GI bleeding. After study there were found to have a bleeding duodenal or duodenal ulcer invasion from a pancreas primary, where the tumor had eroded into the duodenum and caused the ulcer. And the etiology of the patient’s bleeding is likely due to deep created ulcer at the apex of the duodenum resulting from tumor invasion and GI bleeds secondary to tumor invasion and ulcer.
12:09 So the patient was also … outflow from stomach, explains his lack of appetite. So this is like an incidental finding, it wasn’t the reason for admission, but after study, they also found that the patient had a gastric outlet, obstruction secondary to do a duodenal stenosis from the tumor. Since the site causing the bleed was the do, do a … which was metastatic from the pancreas, in this case, the Principal diagnosis would be 74, and someone may question, why aren’t we using the the Ulcer Code? Well, if we go to the Index and we go to ulcer malignant, it says to see the neoplasm malignant by site. So we do have the guideline that says, you know, if they’re just treating the complication, we code the complication first.
12:47 However, in this specific case, the ulcer malignant does code to the Neoplasm if you take a look at the ICD 10 CM Index. So we recommended that the PD XB change, to see 74, which is the secondary malignant neoplasm of the Duodenum. And we have our secondary diagnosis, I just put one of the secondary diagnosis, we have gastric outlet, obstruction, you can also code. Moving onto the next slide.
13:12 Case indications, we also have our abstraction of the duodenal, which includes construction stenosis, structure of a bolus. And please pay attention. You want to pay attention whether you’re using an encoder logic based encoder or a book based indicator. Encoder. You want to pay attention to your clue includes notes your excludes notes.
13:33 And this is going to be important right?
13:35 If it’s intestinal obstruction versus a stomach: obstruction versus a duodenal obstruction.
13:45 Please note there are no excludes notes here. We have an excuse to note here. I don’t see an excludes one notes or instructional notes saying that we can’t code this with the cancer. So it looks like we can code that as a secondary code. Again, they’re admitted for the bleeding ulcer, which was contributed to the cancer.
14:04 But I did want to point this out to you guys. And so, moving on, I do have a lot of questions about this, in contrast coding intestinal obstruction.
14:13 So we do have a A An instructional note under under other intestinal obstruction. other stenosis, obstructive … X There’s an excludes OneNote, so and excludes OneNote means that we can’t code the condition, right? These two conditions together. But it says Intestinal obstruction due to Specified Condition Code to the condition. So, if we have an intestinal obstruction and this is different than a gastric or small intestinal instruct obstruction, if this is.
14:45 I do a genome. We have a separate code. Actually, I shouldn’t say that because other sites of the small intestines, I believe go to this code.
14:54 Those have separate codes, right? But we have other intestinal obstruction. I don’t see an excludes one note there, but it says to code to the code to the condition. So we’re not going to code this K 5669. For example, about obstruction due to peritoneal Carson Motto, says, it says to only assign a C 76.
15:14 And it’s the it tells us that because of the excludes OneNote.
15:17 we only code the intestinal obstruction due to the specified condition and we’re going to code to the condition again, looking at these. These are separate codes and we have a specific code for obstruction of do a genome and obstruction of of the gastric outlet.
15:34 OK, so let’s get into our procedure. Now I’m reading this. It doesn’t really make much sense to me, It’s something I’ve never seen before. So how are we going to approach this, right? What’s the first thing I would do? I’m gonna read the op report. I’m going to consider what is the intent of the procedure. Or they dilating, or they bypassing, or they draining something.
15:55 If I’m not 100% sure, I can do a little bit more research, right?
16:00 Let me You know, we’re going to read this. We’re going to read this in some detail and then we’re going to kind of talk about what exactly they’re doing.
16:07 So, in this case, the procedure is called a endoscopic ultrasonic Guided J G J G J G J by fast. Sorry That’s a tongue twister, get, or a gastro …. So an upper endoscopy was advanced into the duodenal malignant. Stricture was found in the second portion of the Dua Genome and was Don Transverse with endoscope. Along Visa glide, Guidewire was advance through the structure and coiled in the J genome. They index the endoscope is removed, leaving the wire in place, a 20 mm stone extraction balloon catheter was advanced the guidewire under fluoroscopy guidance. The balloon catheter was advanced into the …, the balloon was inflated, and the small bowel woman was distended. It kinda does sound like a dilation right?
16:53 Let’s keep going The balloon was inflated, and the small bowel lumen was distended with a mixture of methylene, blue contrast and Celine, a curvy linear endoscope, echo endoscope advanced into the stomach, the distend it.
17:06 Just do a … distal to the Dua, duodenal structure was identified an optimal position for placement of Illumina opposing metal stents. For creation of a gastro J gentle NASA Moses was found a 15 mm by 10 mm katari assisted lumina posing metal. Stent is deployed under florist scopic, an endoscopic guidance. using a free hand technique free. Flow of the blue dye was solution into the gastric blooming across the stent was visualized the stent and the newly created … track were dilated using a balloon small bowel mucosa was visualized across the lumen opposing stem. So, how, I mean, visually, I’m not really seeing this kind of thinking that, they’re putting in some sense. But, where exactly, are they doing this? So, for me, I would be going to, you know my, my, my visuals to, see, to kind of visualize what they’re doing. Maybe. If you’re a surgeon, maybe this would make sense. to me. I need a visual to kind of understand what they’re doing.
18:02 So, is the intent here? Just based on what we have to dilate anything, it looks like they’re creating some type of connection between the gash, the stomach and the J judum and bypassing that structure.
18:16 It’s kind of what it sounds like to me, but I want to visually see that and I have another slide coming up.
18:21 So they talk about the obstruction was secondary to the pancreatic cancer, they do a EU S guided gastro, digital bypass procedure with a stent. Sent was provided a new opening from the stomach and into the small intestine. Does a stomach normally enter it? and they, if the J genome, right, does a stomach normally open to the genome? That’s what I’m thinking as I’m reading this.
18:44 So taking a look at the comments, they are bypassing the obstruction. So that’s the one comment I got. Every the one person is saying that they think it’s bypass.
18:53 So are they really dilating or are they really draining anything? So let’s take a look at what they’re actually doing. And there’s different I was able to do some research. I put a link to the reference. There’s different techniques for this.
19:06 So to me, it looks like they’re kind of using this technique where they’re inserting the guidewire around the tumor. So we see the tumor has here. And there’s an obstruction there. So if you think about it, the food, if a patient eats and the donut nutritional, and they’re throwing their vomiting up their food, I can’t pass this tumor, so they can’t digest it.
19:26 There’s no wait for that, that food to make it into the small intestine. So they have to create a way for this, this food to get into the small intestine, right? Because of this tumor that’s in the way causing an obstruction.
19:40 So they create this, they insert this, the stent that they’re talking about. They may put a balloon and they put the guidewire, put the balloon in. and then put this stent in place, you can kind of see it better here and they put this stent in.
19:55 And they create this new connection from the stomach into the genome and that the patient is B is able to nutritionally, have a better quality of life.
20:06 It kind of decreases the symptoms of vomiting after they eat. They’re able to tolerate more oral intake, increasing the patient’s quality of life. So you can see here how they do that again. There’s different techniques. There’s the direct technique where they just put this lamb’s stint in here and then the food is able to pass and pass that obstruction. And that’s, you know, kind of technically it’s still functional this area but the tumor is kind of being bypassed, right? That food can bypass that tumor.
20:37 B, We have the, the balloon assisted technique, which is kind of what we saw in that Opera report. Then we have the balloon occluded gastro … bypass. and then we have the Rendezvous guidewire technique and some of these I don’t really know the difference between some of these. But these are some techniques that you may see. And there’s more, definitely more and more time than I have to present during this presentation.
21:04 But if you see other types of techniques, it’s just a technique, right, we don’t worry about that in terms of PCS coding.
21:13 But I do have a link to the reference. If you need more, they go into much more detail about the different techniques in this reference.
21:23 So just to kind of give you a visual to me, this really helped me understand what they were doing.
21:28 And here’s the fluoroscopy that they use, to kind of confirm placement. And you could see different A It’s the Guidewire Advanced, across the stricture site. B We have insertion of a special double balloons balloon. C We have inflation of a double balloon.
21:46 D injection of fluids into the target J genome to induce Distension, And then deployment of the lumen is in, is E is the figure E The self expandable metal sent to allow passage of food, and to allow, allow that to occur.
22:04 So I hope those visuals helped. It definitely helped me. But sometimes that’s what we have to do, right? We have to do a little bit of research to understand what we’re reading. Once you kind of see it, It kind of makes a little bit more sense, right?
22:17 The next thing I wanted to talk about we talked about the intent here is to bypass that, bypass that obstruction and this kind of gets, you know, what someone might ask, What is problematic about coding this?
22:33 So if we if we’re using a logic based encoder, it’s going to make more sense why it may be problematic. And I see this happen a lot. We’re coders.
22:43 I don’t, I guess, for lack of a better word, they get a little lazy, and they just kind of go through the pathway, OK, this code looks good.
22:49 I’m going to use it without doing a little bit.
22:53 You know, bit more research, say, Does this code make sense with what is going on in, in this case?
23:02 So let’s, let’s start out. How are we going to index this? If you’re using let’s say a logic based encoder?
23:10 If you’re using a book based encoder, you may not have this problem, right? But I’m going through, I chose Gastro … me! that was one of the options and asked me, bypass Drainage Gastro JJ. You asked me, first of all, we have to know it’s for bypass. So I’m going to choose bypass. Because that’s the intent. We want to understand the intent of the procedure. Then I’m going to go. Then the next option I have is open, or percutaneous endoscopic. Was this percutaneous endoscopic or open? Does that make sense?
23:38 Does bypass stomach to J genome, percutaneous endoscopic, approach, makes sense for this?
23:51 OK, so To me, it does not make sense, right? Because it’s, it’s via natural or artificial opening. It’s via an endoscope via the mouth.
24:01 Right?
24:03 So, let me go to the next slide. OK, so, I’m going to do a little bit more research. I want to see if there’s a different approach here. It was via endoscopy, right, we didn’t, it wasn’t via laparoscope.
24:14 So, I’m going to kinda take, go through a different pathway and see if I can find.
24:20 I’m going to see if I can find another way to get to this code or at least do a little bit more research. So, next, instead of starting with … me, I’m going to start with Bypass. So bypass, I’m going to choose.
24:36 I’m going to use Stomach to JJ Genome and I see an option for gastric bypass. I’m not sure if that’s the correct option, but then I see, oh, we do have an … two. So I’m going to choose J junior. Here, and then I get opener, percutaneous endoscopic, again, which includes laparoscopic. Again, it’s not laparoscopic.
24:57 It was via an E G D Um, still that does isn’t quite makes complete sense to me. We also have the option to select a device which is a little bit better than the other option. There are, and they are inserting a stent kind of like what we see with a VP or ventricular peritoneal, shunt. We use synthetic substitute that for the catheter being placed. So this one is a little bit better because we have an option for a device.
25:23 So I like that, but again, we still don’t have an option for percutaneous and or endoscopic via natural or artificial opening. Is there a better code? You know, instead of playing around with my my encoder trying to find another way to get to my code, I’m just going to go to the book.
25:40 No, I’m not going to waste any more time with this. Let me just check the book and see if there’s another, a better option in my code table.
25:47 So let’s do a check the book. So I go to my table, O D one, medical and surgical gastrointestinal bypass. And I go to my body part, we’re gonna go to stomach.
25:57 Um, then we’re gonna go, oh, wait a second. Why do I have an option for via natural artificial opening endoscopic? That’s what I’ve been looking for.
26:05 There is an option for natural, or artificial opening endoscopic. I’m not sure why it’s not showing in my encoder. Maybe I’m going to the wrong pathway, I have no idea. And then I see we have a synthetic substitute option. And then the qualifier is J Juno.
26:19 So I tried all my pathways and my logic. I’m not happy with the Code. I go to my book and I’m able to find the correct code. So sometimes you kind of have to, you know, kind of figure things out. Just react to your code doesn’t make sense.
26:33 Do I need to do a little bit more research?
26:36 You may have to.
26:37 So I want everyone to kind of take away from this. We want to react to the code we assign. We want to dig a little bit deeper. If the codes don’t appear, 100% correct, we can research use Coding Clinic. We can go to our code book after some research. Maybe that’s the code we’re left with.
26:52 Maybe the closest equivalent would be no, percutaneous, endoscopic and someplace. Sometimes it is because we don’t have an option.
27:00 For natural or artificial opening endoscopic and previous coding clinics, I’ve told us to use percutaneous endoscopic as the closest equivalent, when we don’t have an option. So that’s where I’m going with this, you know, sometimes we do have to take us to kind of think critically and say, you know, not just code to code. We want to code and react to what we’re coding. Is the DR does it DRG, look a little crazy?
27:26 Know, and this might And so looking at our final codes, here, we have, We changed the PBX. We could change decoder initially coded this to dilation, which would be incorrect. We did see a stent. See, that’s the other thing. We did see a stent insertion but based upon a little bit more research, we found out, they’re not actually dilating They’re using their dilating the stent. Once it’s inserted. But they’re actually bypassing that portion of the Intestine that’s obstruct it, right. So, you can see how you know, doing a little bit more research might get you to the right code. Also, checking out your code book might get you to the right code, as well, checking, you know, Googling it.
28:01 I did provide the references here, the National Center for Health. and some endoscopy, GI published articles. They have some good pictures, some good definitions, things like that in some of these articles.
28:20 Someone’s asking me to clarify, how do I know it’s it’s via endoscopy, right, endoscopic’s.
28:27 The Upper endoscopy was advanced into the duodenum. This was via the mouth, right? How else would they get an endoscope? In here, they didn’t make an incision.
28:39 It’s via an endoscopy’s via the mouth.
28:53 OK, so someone’s asking, How did we choose synthetic? So is the device? Is a synthetic? Is it is A stent? Is a stent or toggle? Is it from the patient? Is it non otago says that some some type of tissue.
29:08 Or is a stent a synthetic substitute?
29:13 If you’re not sure about that, you can check out what the proper code is for a VP of the ventricular peritoneal bypass, or shunt.
29:23 They tell they advise us to use synthetic substitute for that stent or tubing.
29:40 OK, so, so, when advised me that, if, you know, depending on the way you may be able to get it by going to bypass other than GI, then stomach then approached and device, then J Judum.
29:51 And there may be a way to get to it, But, if you’re kind of, you’re fighting with the system, is kind of where I’m going with you, Instead of wasting your time, trying to figure out, how do I index it? And, to be honest, I don’t even think coders get past that. They don’t research. My point is, you know, some coders don’t even research, they just get the code that they get, and they stick with it, they don’t do a little bit more research. So that’s where it becomes problematic, right?
30:14 And going back to my statement is, you want to react to your code, does that make the cut code, make sense?
30:21 Is it a dilation? Is it, should it be a bypass? Is it?
30:26 No, is it open? Is it laparoscopic? Is it via an endoscope?
30:31 Those are the things you kind of want to think out. Oh, I have an open code. Is that correct? You want to react to your code because maybe you chose the wrong option when you’re going through the encoder and not all of us use a logic based encoder. Some of us use the books. You may not have the same, this this may not be problematic for you. But I do know a lot of probably a majority of us do you use a logic based encoder.
30:59 OK, so it looks like that makes sense to everything and they would obviously if it was sent, if it was other something other than synthetic, they would have to you know, they would indicate that in the procedure note, as someone has, has mentioned.
31:14 Yes, OK, Understanding intent and applying the correct root operation, so we have pulmonary artery, arterial …. Now some of you may not ever see this, but that’s not really the purpose of what I’m trying to get at when I’m going over this, and maybe you learn something from from this as we go through this.
31:33 But taking a look at this procedure, we have pulmonary a main pulmonary artery arterial … using a photo fixed patch.
31:40 A left pulmonary artery or arterial plaster using a photo fixed patch, and as we read through this op report, is that is the the root operation dilation insertion supplement.
31:51 I don’t know, repair other route operation based on the intent of the procedure. So we have a patient as a newborn. The patient was diagnosed with tau SIG big heart.
32:06 And they had a complete repair. They don’t say specifically how they, how they had a complete repair. So I’m kind of guessing here. But bear with me. The patient stayed on ECMO for five days, and then he had a delayed’s journal closure. You develop a progressive … artery stenosis in the main and the ******* of the left pulmonary artery. So we’re going to talk about what valve you learned some valuable pulmonary artery stenosis is. But we see this a lot with congenital repairs.
32:33 A lot of times, they’ll develop over time these pulmonary artery stenosis, so it could be a progression or part of their congenital anomaly. It could be, I estrogenic, we just have to pay attention. And look for that in the, in the record, we may need to query to, if it’s not clear, but, really, I’m focusing on the op report here.
32:55 There’s some more information there, but it doesn’t pay attention. It doesn’t play into our assignment of the code, So I’m going to skip down to where they’re actually doing the procedure. They did put, They did open the …, this journal area up.
33:07 They put the patient on bypass, I’m kind of summarizing what they’re saying in that section, just for time purposes.
33:16 With the heart beating, the ******* of the left pulmonary artery at the distal main PA was in sized.
33:23 We found a duct or swinging the ******* of the left pulmonary artery and then the left pulmonary artery was opened for one centimeter to a much more normal looking vessel. Then another incision was made on the main pulmonary artery from the first incision all the way to the sino tabular junction. We inspected for the commissioner and there was an interior commissioner. Therefore, we extended the second incision all the way down to the annulus of the valve, but towards the left side and closer to the heart.
33:48 Are the aorta sorry, not hartt closer to the aorta.
33:52 So what do you know? Let’s keep going. Actually, this is, there’s another page here. There were some effluent from the left pulmonary artery that was easy to control with a … sucker. On T, we had performed a bubble test in the beginning and there was no air on the left side. Therefore, the first patch was brought into the field. So you can see here I have a little picture where they had made an incision and they’re putting a patch there. It was brought into the field and cut into the appropriate shape and configuration, so just so we have a visual of what’s going on, I left pulmonary arterial … was performed with a 6, 0 proline suture. We then completed the arterial …, you have the left pulmonary artery, we could easily push a … with no problems. Then a second oval shape patch of photo fixed was cut. We use that: we use that to create an extensive into your main pulmonary arterial …. We made sure that in the left interior scientists of the pulmonary route, all the structure of sutures are all the way from the leaflets of the pulmonary valve. On the left side, the two patches where NASA most entirely to create a nice transition point from the main to the left pulmonary artery.
34:56 With when that was completed, we started ventilating, and then they took the patient off bypass, et cetera, et cetera, et cetera.
35:07 Um, So what is that tossing Bing anomaly?
35:16 It’s a congenital heart defect, So it’s probably helpful that we understand what it is in order to kind of help us understand what they’re doing here, in which, the patient is at both double outlet. Outlet right ventricle is commonly abbreviated, D O B R, D O RV, and a sub harmonic venture, Trexler, Septal defect. And then, so, in the DOR V or the double outward, right ventricle. Instead of the normal situation, where the blood from the left ventricle flows out to the order and the blood from the right ventricle flows out to the pulmonary artery. Both the aorta and pulmonary artery or connected to the right ventricle, and the only path for the blood from the left ventricle to cross the V S G. And when the …
35:57 harmonic sitting just below the pulmonary artery, the LV blood, then flows to the pulmonary artery, then the RV blood, by default flows mainly to the aorta.
36:06 Of course, this isn’t a correct blood flow through through the heart and mean vessels. It’s also similar to the the transposition of the great Arteries. The repair may be the same or different. But basically, it’s corrected via an arterial switch operation.
36:22 There are some there. They can also be managed by ever Stelly procedure.
36:29 And there’s, depending on what they may choose a different technique to repair this. But you can kind of see here what they did do to repair it. You can see them.
36:39 They may put a Grafton here, or they may do a flip flip the artery the arteries. It’s very complicated. But just to kind of give you an idea of what they’re doing, I really want you guys to pay attention to the anatomy Here of the pump. This is the left pulmonary artery, the right pulmonary artery.
37:01 And in this case, we have, you know, a picture of what the pulmonary super, I should say.
37:09 The super valve stenosis looks like, sorry, there are kind of small. Sub valve. Stenosis is below is situated are occurring below the valve. And super stenosis is occurring or above or above the valve.
37:24 Um, so you can see here, this is above the valve.
37:28 They’re making incision, they’re putting in there’s different patches.
37:32 I Don’t know why this looks blurry, but when I did it on the original slides, it didn’t look this blurry, but I’m sorry about that. So, you make an incision, they put this passion to repair that stenosis, um, there’s different techniques depending on where the stenosis is located. So you can see here, here’s different, you know, they kind of repair the main pulmonary valve. The left pulmonary valve using one patch, we saw in our example. They actually use two different patches, right? To repair the artery. This is the tooth example, we have a two patch repair. So the left pulmonary artery, the main pulmonary artery, the right pulmonary artery, in our case, they did the main pulmonary artery, and I believe it was the left pulmonary artery.
38:15 Yes, the … VR would be on a newborn. You chair, you’re typically going to be diagnosed as a newborn.
38:22 It’s congenital.
38:23 So if we take a look at our options here, and look up the definition Arturo … is defined as a surgical reconstruction of the wall of an artery. And angioplasty is defined as expanding a vein or an artery.
38:35 one can argue that they are, they are, you know, maybe they are making a decision into the wall of the artery because of the …, and they’re dilating it.
38:44 But if you take a look at oh 2 7, the dilation table We only have options for inter luminal device or no device. So, I don’t think that’s going to fit our example. If we look at the definition of dilation is expanding an ******* or lumen of a tool or body parts. So, again, one can argue that’s what they’re doing, because they have a stenosis here.
39:03 It can either be via percutaneous viana, angioplasty, as an example, or maybe an internal incision, to release that pressure.
39:10 So one can argue that repair. Remember repair does not include a device. It’s just restoring, to the extent possible, a body part to its normal anatomic and atomic structure. And function.
39:25 So using a suture, for example, we don’t it doesn’t include the device. So, what do we do when we don’t have a repair coat, you know, repair, not elsewhere, classified with a device?
39:35 We would code supplements. So, supplement includes repair with the device. I believe I said, we believe, but I believe that this is the best fit and replacement.
39:44 In this case, they’re not replacing the whole artery, they’re just putting a patch on part of the where they made that incision.
39:50 Um, so, taking a look at this, in my opinion, the best option here supplement left pulmonary artery, and one, what is one is I know someone’s going to ask me, How do you know, it’s the plastic tissue that photo fix. You’re gonna have to look that up, right in the chart. They may say what type of device it is. But if you go to that, I put a link to the device information. You can see that it’s bovine tissue. So, bovine tissue would be classified as … plastic tissue.
40:18 So, reconstruction of an artery we’re gonna go to supplement, left pulmonary artery with …, plastic tissue and of course it’s open BSD anatomy.
40:29 Um, and that’s kind of where we’re going with this.
40:31 Again, it requires some a little bit of logic, too.
40:37 Come up with the correct code here.
40:42 Let’s take a look to the next slide. We do have some other and the reason I wanted to talk about that, I know that’s a little bit complicated.
40:49 A lot of you probably don’t even see those types of things at your facility, but these kind of kind of tie in with some coding clinics that we have seen recently. So we have a six year old female. She is admitted for treatment of trunk trachea bronchus Malaysia, and underwent an endoscopic placement of a trickier bronchioles stent.
41:07 We’re unsure whether to assign the root operation supplement, as the surgical objective seems to be reinforcing the walls of the trachea other possible operations, or deletion or insertion. What is the appropriate route operation for the surgery? So, we’re going to assign the following code. Supplement trachea with synthetic substitute, be a natural, or artificial opening endoscopic.
41:27 So the root operation supplement is more specific than insertion, because the stent is being placed to reinforce the collapsing trachea. This procedure does not meet the full definition of dilation. The procedure does not use inter luminal pressure incision into the wall the trickier to expand the lumen of the trachea.
41:43 So even kind of see how this relates back to that previous example.
41:47 I mean, that, in our, in our example, they didn’t make an incision, one can argue they made the decision to make the patch, et cetera.
41:55 But we also in under dilation, we don’t have an option for dilation and supplement or without with a with an option there. The only option that we have there is dilation with inter luminal device or no device and they did place a device.
42:11 So, that’s the other reason we went with supplement in that previous example.
42:18 So, another example, and I have seen coders using the root operation insertion incorrectly.
42:24 So if they’re doing an angioplasty for C a D, they’re using a balloon to expand that ******* or that kubler body part.
42:33 Because they have CAE, they have a stenosis there.
42:36 Are we going to be coding insertion of the stent, or are we going to be coding dilation with?
42:41 And with it with a stent.
42:47 Be careful.
42:48 Be careful with that, because I have Sometimes I’d again, We want to pay attention to what we’re We’re indexing or what we’re choosing in our encoder. Remember, it’s a tool to get to our code faster, but we still want to react to that code.
43:01 So in this case, this is kind of the opposite of Patient underwent, and we’ve talked about this example before on previous roundtables. But a patient underwent rotational a threat to me and stenting of her coronary artery following a rotational. A threat to me angiography revealed the perforation, the proximal circumflex coronary artery.
43:19 A balloon was advancing and fleet, it followed by deployment of a Joe Med grandmaster stent to seal the perforation provider document, The perforation of successfully repair treated with the Joe Med grandmaster.
43:30 What is the appropriate route operation for deployment of a Joe Med graph must spend to repair treat the coronary perforation. Again, they’re not doing this angioplasty with balloon or sten for stenosis, right? To the read, the intent isn’t to dilate. The intent is to repair that perforation. So we have an option. We have the Option to Use Supplement is the appropriate route operation for the deployment of the synthetic graft to repair treat the coronary perforation. In this case that the graph master stent was deployed to seal the perforation of the proximal circumflex artery. Although stents are often used for dilation of a vessel, they can also be used to reinforce or augment a vessel to supplement is the appropriate route operation.
44:13 So, again, using our law the logic here you want to be careful, are you dilating, are you supplementing, what is the reason they are placing the stent?
44:25 And, again, be careful if they’re doing a dilation, if they’re doing a angioplasty for C a D, are we going to be coding insertion?
44:35 The answer is no because we’re going to be coding dilation with stent because the intent is to dilate, Right? So be careful with choosing insertion in your encoder.
44:48 And say, Did they have an option as it can to bring me to dilation if I choose insertion? Or is it just going to bring me to the insertion code, You can try that way.
44:56 But you want to make sure that you’re using your logic and you’re, you know, you’re implying the root operation successfully when you’re applying that code.
45:05 Is this really dilation, should it be supplement? Are they really dilating or are they reinforcing and sealing up this perforation?
45:13 In the case of the CAV dilating because they have a stenosis and they’re using pressure to open up that vessel And then placing a stent to keep it open, right?
45:23 So be careful with that, I do see coders using insertion. Those codes were created, I don’t think this year, the year before and I do see coders. I knew that would become a problem I have. We have seen coders using insertion incorrectly.
45:36 Now that we have tables for insertion of stent.
45:41 And here’s another example.
45:43 revision of previous trunk, Chris Arterials to surgery with a venture called the pulmonary artery Conduit. So they created a conduit, just to summarize.
45:51 They created a conduit and they also augmented the pulmonary graphs. So they tell us that, you know, how are we going to code this arena? They also And didn’t they also did they also had a stenosis and a stent was placed to open up that area.
46:08 So in this case, they’re telling us that we should be going the bypass for the ventricle for that conduit, then they’re going to code dilation because they dilated the pulmonary artery with an inter luminal stent. And then they also supplemented the pulmonary artery with nano ….
46:23 In this case, there is no, no chocolates tissue substitute for the patch allograft or Patch NGO graph for the for that as well. So, this is a little bit complicated, but just showing that there are different examples that you can utilize in eating your decision process.
46:40 When you’re deciding on a code for a procedure, does it meet the intent?
46:47 OK, so next, moving onto my next example, Val … with a Watchman device.
46:52 Now anyone that knows anything about a watchman device, do you want to tell me in the comments why that wouldn’t make sense?
47:02 Good point. So talking about … stents can also be used to restrict.
47:07 So good point.
47:08 So you want to keep in the intent in mind when we’re when you’re thinking about why they’re placing that stent. Is it for dilation? Is it insertion? Is it supplement? Is a bypass. You know, there’s all different kinds of reason. You really want to understand the intent of the procedure in order to apply the correct operation.
47:31 OK, so … with Watchman device, does that make sense? Let’s kinda keep going. And I’m really proud of this coder that kind of came across this and kind of took that second, you know, had that question. And you know, the light bulb went off her in her head and said, This doesn’t make sense. I’m going to do some more research and figure this out. So in the off report, it says the patient, you know, they have a history of smoking.
47:55 They have, um, mitral stenosis likely it’s dramatic. They have severe pulmonary hypertension. They’re coming in for a valve ….
48:05 They placed a wire, a …, a wire, They used the balloon to dilate it. They did several dilation ends.
48:13 Um, the valve or Ery expand it, et cetera.
48:21 Then, in one of the part of the procedure, they talk about a transept or puncture watchmen was performed. So she’s thinking, OK, a Watchman procedure was performed, it doesn’t make sense. There was no other information about them placing the device. I guess we kind of have to understand what a Watchman device is in order to understand that they didn’t place a watchman here. But let’s see what happened. They say transept puncture, watchmen and a mitral valve your ….
48:52 OK, so let’s keep going here, OK, so a couple of comments.
48:57 Um, they believe a watchman to treat a-fib, the Watchman usually is as inclusion sensor used to restrict blood flow. OK, I’ve previously read that. So let’s keep going.
49:11 And the inventory, no Watchman device, is it a device? Do we see anything about a watchman device here?
49:18 I don’t, so that’s the first clue.
49:21 So initially it was could it repair that would be incorrect a dilated the mitral valve. So it’s gonna be co delight dilation of mitral valve. So that’s the first correction.
49:31 And decoder did catch yourself on that. So she picked, she coded the fix, the, the the root operation for the mitral valve insertion of intro luminal device into the left atrium. That would be incorrect.
49:44 So, because there is for occlusion of the left atrial appendage, we’ll get into more about what Watchman device is. If they inserted it and then removed it, we can just code the insertion. But the intent there is to exclude the left atrial appendage. But there is lacking documentation. So what the coder did was reach out and say OK I don’t see enough documentation to code this mitral valve, and if you really think about it, what are the indications for Watchman device?
50:10 As someone pointed out, it’s eight for a-fib to prevent embolism or stroke, but it’s a specific type of a-fib, right?
50:20 And also, as Watchman device listed in the device inventory, the answer is no.
50:25 So all of those things decoder kind of had her thought process. She wasn’t convinced that a watchman was actually placed. So I left it Decoding Management to Review, they’ve researched and found that the word watchmen was included with … or puncture, in the dictation template. So, this is an issue, right? There was something in the dictation issue, template, that caused the coder to potentially code this occlusion of left atrial appendage.
50:49 Um, so it’s actually a typo of sorts. No, watchmen was actually placed. You can see an inventory. There was no watchmen that was placed, so that’s the second clue that the decoder was actually previously a transcriptionist. So that kind of aided her knowledge that easily mistakes could be make made.
51:07 So, always a good idea to do a little extra checking if you suspect something doesn’t add up. And I, and she was glad that she did in this case. So that’s the lesson learned, in this case, but let’s also take this a step further and take a look at a Watchman device so we can easily go to the website of the Boston Scientific website and look up. What are the indications for a Watchman device? First of all, they never documented a-fib.
51:30 So, but it’s specifically for non vascular a-fib patients that are at increased risk for stroke and recommendations for anticoagulation, they’ve chads score. It’s here or they suitable for wave warfarin or Coumadin. Yes. Does the patient has appropriate rationale to seek a non pharmacological alternative or Warfarin? Yes, And what are those indication, history of major bleeding? While on anticoagulant?
51:52 Coagulation therapy?
51:54 Prior patients prior experience with anticoagulation, so inability to maintain a stable INR, medical conditions occupational lifestyle that place the patient at risk for high height, major bleeding. Secondary trauma, presence of indications for long term way for and use. other than non valvular a-fib, mechanical heart valve, …, states, recurrent DVT, etcetera. So we didn’t even see the patient had a-fib, so it’s kind of not making sense. That’s another indicator here that perhaps this is education error.
52:28 So the point is here is no that, you know, there’s not enough information here to to apply the correct, the correct that code for the Watchman device. There are some clues in the body of the op report here that it was incorrect.
52:48 So I just have some other references, I’m not going to get into the actual procedure. I do have some pictures here.
52:56 Here’s what the device looks like: um, but if you’re interested in learning more about the, though, I did do a previous roundtable on watchmen, I think, I believe it’s in the cabbage the cabbage one. If you’re interested, it’s at the end of that webinar roundtable.
53:09 Here’s some more information about about the device. I took a picture from the, the, the website.
53:18 And you could see what it looks like, but basically the my point here was, you know, sometimes we do have to do a little bit more research if something doesn’t make sense. So, that ended up being a dictation error.
53:30 So, in summary, React to your codes.
53:35 Does the code make sense? Does a DRG makes sense? Maybe you have a laparoscopic procedure, and you coded it to open, and that’s what’s, that’s what’s impacting the DRG and you have an open, I don’t know, open an appendectomy or something like that, and it should have been coded to laparoscopic etcetera.
53:51 You want to make sure you’re checking your book, tabular, an Index, pay attention to your notes, your inclusion, I mean, more for the CM codes, check, your book Tabular, an Index, appendices, device, body part key, PCS tables, know those that all things can help.
54:09 Check your coding references, your coding clinic for similar scenarios. You want to research device information like we saw with some of them. So would you know that a photo fixed was a zoo, plastic tissue, unless you looked it up? No, right?
54:20 It may be in the device key, but if it’s not, you can just Google and go to the website that and find out what type of device it is.
54:28 Um, and or understand the indications and intents of procedures, there’s a lot of information.
54:33 So, if it’s a newer type procedure, there’s a lot of information that you can utilize on the maintenance meetings and things like that. You can reach out to your manager. Do they have information? You can reach out to other resources. You can Google it. You can go to YouTube.
54:49 There’s a lot of good information and even your hospital. So, for example, I know that, for example, University of Pennsylvania, they do a lot of heart procedures and they have a lot of great information on their website about, let’s say, valve and valve.
55:03 Heart replacement, Heart valve replacement. So, that might be a good place to take a look, and, you know, if you’re working for, you know, different another facility, that might be a place, You know, you might go to your own facility and see what exactly what they’re doing in that procedure. They have patient education there that can help you understand what exactly they’re doing during that.
55:22 That procedure, especially if your facility is known for, let’s say, heart procedures, or you’re known for GI procedures, you’re no known for transplants, they have a lot of good information on your own, Your own website, or in your, you know, you have a shared drive that you share with. You know, your coders make sure that your use of utilizing all those references.
55:39 If no code or advice exists, consider reaching out to the co-operating parties in our Coding Clinic for Advice. Sometimes they’re related to index and tabular issues. There is a specific e-mail address that you can e-mail, and I put those on the screen there.
55:55 I had someone asked me recently, can I submit it? Can anyone submit a coding A question to Coding clinic? Yes. And it’s free. So that’s right from the website. Submit a question. Submit a question for your staff to read our staff to review.
56:05 There’s no charge to the service, just create an account and submit your question, And, of course, you don’t want to submit every coding question that you possibly have. Those are, you know, there’s ones that defy logic. You’re not, you know, after all, exhausting all of your options, you’re completely not 100% sure on how to code code that maybe there’s no body park, nothing in the body part key that says, you know what you should use for?
56:28 For, I don’t know, orbital apex or something which goes to orbit but, you know, some weird body part that you’ve never know or space of, a body part. I’m trying to think of the one that I saw recently, and I can’t I’m, not, I can’t draw it from my memory for some reason. But anyway, you know, sometimes, you don’t know, you’re not sure of body part to use things like that. You can request more information, submit questions if you want to suggest an index term, et cetera, et cetera. A definition. You know, does this meet the definition?
57:03 There’s good references there.
57:06 So.
57:10 Someone’s asking me, where do you submit coding clinic questions? I have the website right there, WW dot coding Clinic advisor dot com is Coding Clinic questions.
57:25 OK, so that’s officially the end of our presentation today. Hopefully you found that helpful. Thank you so much for attending. I will stay on for a few minutes.
57:35 Um, She answer questions.
57:39 So, I do have some people telling me just if you’re if you do code, the Gastro JG, you don’t bypass.
57:45 They said if you start with E G, D, and choose it that way, you should be able to go get to it. Not everyone chooses the same pathway. So, if you go through a different pathway, you know, you should still be able to get to the code.
57:58 So, know, that was kind of my point, you know, instead of, you know, you’re fighting with how do I get to this code? But there is a way so someone did mention that there if you go through EGCG, you should be able to get through to get to that code get to the code without going to the book.
58:16 So thank you for pointing that out. So pathway in three M bypass other gastrointestinal stomach, the unnatural artificial opening.
58:26 You can start with EG D, This will also bring you to bypass.
58:31 So, going back to that … procedure, it was all done via E G D. So we wouldn’t be using percutaneous.
58:38 It wasn’t via this, like, They didn’t make an incision and insert A tube, it was all via the, E G D, Um.
58:51 OK.
58:56 May go to the next slide.
59:00 Someone just a comment, this is Why someone the sun is, I’m just reading comments now. This is why someone prefers a book based encoder and some people do, right. Some people like a logic based encoder. Sometimes it can save you some time but sometimes it lead you in the wrong direction. You know depending on how you index things so that’s why it’s very important that we have a strong understanding of root operations and their definitions and that’s kind of what I was trying to get to in this presentation.
59:25 It’s not just about, you know, plugging something in and getting a code. It’s about applying our knowledge. And our skillset. Coding is more more just more than just applying codes, right? Sometimes, I think the encoder logic or base encoders make us a little lazy and assigning our codes. You know, you really want to react to those codes. Does it make sense? Is there something more specific?
59:52 OK, so, going back to the angioplasty, why wouldn’t this be repair of an artery? So, remember, they put in a patch graph, so repair, not elsewhere, classified with a device goes to supplement, right?
60:13 OK?
60:16 OK, so, um, someone’s asking about CEUs, this is only AHIMA.
60:23 If you are a CX Employee, please refer to our internal group regarding CEU and guidelines.
60:31 I have up on the screen now the link to download your CEU, you will be getting an e-mail with this information, but it’s here as well, if you need it, um, it’s also in the documents that are in the documents screen.
60:55 I think this is unrelated to the presentation. However, I’ll do my best to answer it. Can you, can I ask a question regarding the code of Diabetic and Metabolic acidosis. If we code any Diabetic Condition codes with acidosis, you’ll get an Exclude one Edit from three M, so do we ignore that it? So if they’re unrelated we do have a coding guideline that says if they’re unrelated that we can ignore the edit. Right? However, you, if it’s not clear, if it’s related, you may need to query that.
61:25 I’ve seen some cases where it is related to the diabetes. Some cases, it’s totally unrelated to the diabetes. So without further information in the chart, I can’t really answer that.
61:36 But again, if it’s totally unrelated to the diabetes and you have specific documentation of that, you can ignore the Excludes one edit per the official coding guidelines regarding excludes one notes.
61:58 I don’t think I see any more questions.
62:08 OK, so.
62:16 OK, so another comment: Good advice to keep the root operation: Definitions in plain sight on paper online, That’s a great point. It sounds like a lot of people. Oops.
62:29 I lost my, lost it. It sounds like a lot of people need to refer to that more otherwise too much guessing and room for error. Exactly. So that was why I wanted to have this presentation today and go over some of those things, because, again, it’s more than just, you know.
62:45 Just plugging in a code, it’s about understanding what we’re reading and applying the appropriate root operations.
62:52 And again, good point, having those definitions up, somewhere having it in a folder printed out, in an e-book. You know, having your, your e-book up, having your paper book up.
63:04 Great point.
63:09 Can we, you see use for PMI? Well, I’m not sure what is PMI.
63:19 So someone’s asking me, can you make sure I’m on the e-mail. We do have, you know, some people will not get the e-mail because of your organization blocking our e-mails. So check your spam also. You should be able to download this, the documents right at this point. And it has a link to the CEU. I’ll still be staying on for another couple of minutes just going over some of the questions And comments. So you should have time to download it.
63:46 or you can type it, type it from you know, type it’s on the screen right now: WWW dot … dot com slash resources slash webinars slash coding dash CEU.
64:07 So for this case, where they didn’t affect me instant for the …, and then did the supplement additionally, to correct the fix this. Yes, They were just refer to the Coding Clinic is just referring to the question regarding the perforation repair.
64:29 It’s amazing questions I would have to, you know, get my book out and answer them, I don’t um if you need help with specific coding questions, you can e-mail us at Coding roundtables.
64:39 In terms of your name and a certificate, you can manually put your name on their certificate by editing the PDF.
64:51 Someone just made it a, made a comment, I am totally inspired by this presentation, because I do the research all the time. It takes more time. So, and your productivity is not the best, but at least I sleep at night.
65:03 So, but the next time you get that case, right, your your productivity is gonna go up, so kind of evens out, is what I’m gonna I’m gonna add regarding regarding that. So the first time you see a case, you may, it might take you a little bit longer. But then if you consistently get those cases the next time it’s going to be easy easy peasy, right?
65:24 That’s awesome, you’re changing lives, Janice.
65:33 Yeah. So it excludes mono is between acidosis, NDM Winners Diabetic ketoacidosis. Yep.
65:40 Scott, there’s a typo, I don’t, I guess I’ll e-mail someone. A couple of people noted that, there’s a typo on the CEU, it says ICD 10 PCS, P, C D instead of PCS will, ask marketing to fix that. All right. So that’s, that’s it for today.
65:54 I don’t have any more comments, or questions were a bit over on time, A couple of minutes, but thank you, everyone.
66:02 I’m glad that you enjoyed it, and we’ll see you next time. Take care. Everyone, Have a great week.
66:11 Yep.