General E/M
Regan Tyler, CPC, CPC-H, CPMA, CEMC
Defining “Time” Within CPT®
Page xii
2013 CPT
y On page xii of 2013 Professional Edition CPT®”
™“Time is the face-to-face time with the patient” (unless otherwise
specified)
™“A unit of time is attained when the mid-point is passed”
™When a distinct procedure is performed during the time-based service (eg.
CPR during critical care), the time spent performing the distinct procedure
“should not be included in the time used for reporting the time-based
service.”
™“For continuous services that last beyond midnight, use the date the
service began and report the total units of time”
™For E&M services, time in the outpatient setting is defined as “face-to-face” opposed to
“unit/floor time” in the inpatient setting (Pages 7-8 of 2013 CPT)
What Defines The Level of
Evaluation and Management (E/M) Code?
Page 5-10
2013 CPT
¾
History
¾
Exam
¾
Medical Decision Making
g
¾
Nature of Presenting Problem
¾
Counseling
¾
Coordination of Care
¾
Time
“KEY” Components
Contributory Factors
CPT clearly demonstrates number of “key components” required
1
History- Subjective
• Chief complaint – clear, concise statement detailing
the reason the patient is presenting today, usually in
the patient’s own words
− According to CMS, the CC may be combined with the HPI
• HPI (history of present illness)
• ROS (review of system)
• PFSH (past family social history)
History of Present Illness-HPI
• Location – where is it. (pain in LLQ abdomen)
• Quality – how does is feel –
(diffuse‐achy, tingling, numb etc.)
• Severity – how bad is it (0 – 10 for pain‐adults, 0‐3 kids)
• Duration – how long (3 days)
• Timing – when does the symptom occur (worse after meals)
• Context ‐ what happen to cause it (fell while playing basketball twisting his knee)
• Modifying factors ‐ what did the patient do in an attempt to alleviate their symptoms, and the result. (took otc)
• Associated signs and symptoms –
what else is bothering the patient. (diarrhea & vomiting)
2
Brief HPI
Mr. Jones complains of a worsening sore
throat for which he has been taking
Sudafed.
Sudafed
Mr. Jones complains of a worsening
QUALITY sore throat LOCATION for which
he has been taking Sudafed MODIFYING
FACTORS
Brief HPI
Sally continues to show improvement over
the past 2 months with her cholesterol on
the current regiment of Lipitor.
Lipitor
Sally continues to show improvement
QUALITY over the past 2 months DURATION
with her cholesterol on the current
regiment of Lipitor MODIFYING FACTORS
Extended HPI
Arnold returns today with worsening low back
pain. He has been taking Advil every 4 hours,
and the p
pain is rated a 7 out of 10.
Arnold returns today with worsening QUALITY
low back LOCATION pain. He has been taking
Advil MODIFYING FACTORS every 4 hours, and the
pain is rated a 7 out of 10 SEVERITY.
3
Extended HPI
Patient returns with stable diabetes that he has had for
the past 10 years for which he takes Glucophage. He
finds that his sugar is most unstable just before bedtime
Patient returns with stable QUALITY diabetes that he has
had for the past 10 years DURATION for which he takes
Glucophage MODIFYING FACTORS. He finds that his sugar
is most unstable just before bedtime TIMING.
Review of Systems-(ROS)
• An inventory of the body systems of the patient to determine if the
patient is experiencing additional signs and/or symptoms
• Expand on remarkable symptoms
• A complete ROS (10+ systems) – Positive or pertinent negative
responses must be individually documented with a statement that
captures the remainder of the required review (e.g., remainder of 10
systems ROS are reviewed and negative”). In the absence of such a
notation, at least ten systems must be individually documented.
Review of Systems
• Constitutional
• Musculoskeletal
• Eyes
• Integumentary
• Ears, Nose, Mouth,
Throat
• Neurological
P hi i
• Psychiatric
• Cardiovascular
• Endocrine
• Respiratory
• Hematologic/Lymphatic
• Gastrointestinal
• Allergic/Immunologic
• Genitourinary
4
Review of Systems - ROS
• Complete – inquires about the system(s) directly
related to the problem(s) identified in the HPI
plus all additional body systems.
DG: At least ten organ systems must be
reviewed. Those systems with positive or
pertinent negative responses must be
individually documented.
**For the remaining systems, a notation indicating all
other systems are negative is permissible (or something
to this effect suggesting 10+ total). In the absence of such
a notation, at least ten systems must be individually
documented.
Past, Family, Social History
• Past
− Current medications
− Past surgeries
− Past illnesses/injuries
• Family
− Review of medical events in the patient’s
family, including diseases which may be
hereditary or place the patient at risk
• Social
− Age appropriate review of past and current
activities
Past, Family, Social History (PFSH)
• Complete PFSH – is of a review of two or all three of
the PFSH history areas, depending on E&M category
PFSH = 3/3
PFSH = 2/3
•Office – new patient
•Office established patient
•Initial Inpatient
•Inpatient subsequent
•Initial outpatient
•Emergency Department
•Domiciliary – new
•Domiciliary – established
•Home care – new
•Home care – established
5
History Auditing Reminders
• CC, ROS and PFSH may be listed as separate elements of
history or included in documentation of the HPI
• Provider can use and get credit for history elements (not
HPI) obtained at another visit as long as it is relevant and
referenced
− “Remainder off ROS and PFSH unchanged
g since 11/26/2012”
• ROS and/or PFSH may be recorded by ancillary staff or
patient as long as the provider documents confirmation of
the information
• TIP:
− If unable to obtain a history from the patient or other source,
document the patient’s condition that precludes getting it and you can
be credited for a comprehensive level of history.
1995 & 1997
Documentation Guidelines
The documentation of each patient encounter should
include:
• Reason for the encounter and relevant history,
physical examination findings and prior diagnostic
test results;
• Assessment, clinical impression or diagnosis;
• Plan of care; and
• Date and legible identity of the observer.
6
Examinations- Objective
• 1995 guidelines
− Count the number of systems/areas
− Single system exams are not welldefined…
• 1997 guidelines
− Count the number of “elements” or
“bullets” performed
− Single system exams are defined
− Harder to meet without
templates/macros
Examination Documentation Reminders
Pages 9
2013 CPT
• A notation of “abnormal” without elaboration is insufficient
documentation.
• Unlike history, portions of examination can not be ‘deferred’
• A brief statement/notation indicating negative or normal findings is
sufficient .
• Normal or negative findings must be listed by body area or organ
system.
• Page 9 of 2013 CPT states the only difference between an Expanded
Problem Focused examination and a Detailed examination is that one
is “limited” and the other is “extended”
− You will need to determine which guidelines suit your providers
best and consider local carrier instruction
Determining Level of
Physical Examination
1995 - Body Areas
Body Areas / Organ Systems
Problem
1
E
Expanded
d d
2-7
Detailed
Comprehensive
2– 7 *
1997 -Elements
Multi - Sys
1-5
6 - 11
6 - 11
12 - 17
with 1 detailed
8+
Single - Sys
1-5
12 +
Eye/Psych
18 / 9
=9
All Shaded +
1 Unshaded
organ systems
7
Let’s Apply 1995 Concepts
PHYSICAL EXAMINATION:
VITAL SIGNS: Stable, afebrile.
GENERAL: Awake,
Awake alert and oriented x3
x3.
CARDIOVASCULAR: Regular rate and rhythm.
LUNGS: Clear to auscultation.
ABDOMEN: Soft, minimal amount of tenderness right
upper quadrant, no guarding, no rebound, no acute
abdomen, stool in vault, no hepatosplenomegaly.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 170/75, pulse 96, respirations 16, O2
saturation 97% on room air. Afebrile.
GENERAL: Patient is alert and oriented to person, place and time.
Is resting comfortably in bed in no acute distress.
HEENT: Atraumatic, normocephalic. Pupils equal, round and
reactive to light and accommodation. Extraocular movements are
intact. Oropharynx is clear and moist. No exudate present.
NECK: Supple. No lymphadenopathy.
CARDIOVASCULAR: Regular rate and rhythm. Grade 2/6 systolic
murmur. No rubs or gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, crackles or
rhonchi.
ABDOMEN: Positive bowel sounds. Appropriately tender to palpation
in right upper quadrant. Nondistended.
GENITOURINARY: External genitalia with normal appearance.
Bimanual exam is within normal limits with no palpable masses.
EXTREMITIES: No erythema, no edema. No calf tenderness.
PHYSICAL EXAMINATION:
GENERAL: Resting comfortably in no apparent distress.
VITAL SIGNS: Temperature 99.2, pulse 190, respirations 65,
blood pressure 124/76, weight 6.043 kilograms.
HEENT: Normocephalic, atraumatic, pupils equal, round,
reactive to light, extraocular muscles intact. Mucous
membranes moist and pink.
NECK: Is supple with no adenopathy. Trachea is midline.
CARDIOVASCULAR: Regular rate and rhythm
rhythm. No murmurs.
murmurs
LUNGS: Are clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended. Bowel sounds
present.
EXTREMITIES: Left lower extremity with erythema from the
dorsum of the foot up to just above the left knee with
edema and increased temperature. It does appear to be
painful to touch. No obvious deformities. Range of motion is
intact. There does seem to be pain with motion
8
PHYSICAL EXAMINATION:
This was a young male who was currently intubated and
sedated on the vent.
VITAL SIGNS: At time of examination, showed a pulse of
110, respiratory rate of 22, blood pressure 195/102.
HEENT: The patient has a craniotomy scar on the left
side.
CARDIOVASCULAR: S1, S2, regular normal intensity, no
rubs or murmur appreciated.
RESPIRATORY: The patient has moderate rhonchi and
creps anteriorly, no wheeze auscultated.
GASTROINTESTINAL: Nondistended, bowel sounds
positive.
NEUROLOGIC: The patient was sedated.
EXTREMITIES: SCDs. (Sequential compression device)
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 130/80, heart rate is 82, respiratory rate 16,
temperature 98. Saturating 98% on two liter of oxygen.
GENERAL: Patient is alert, oriented x3, in no acute distress. He appears
somewhat drowsy. He is laying down in 30 degree head-up position in no
respiratory distress.
HEENT: Positive PERRLA. Sclerae nonicteric. Conjunctiva pink. Oral mucosa
moist and I could not evaluate the JVD due to patient's thick neck and large
body habitus. No carotid bruits could be appreciated. Thyroid within normal
limits.
NECK: Supple.
CARDIOVASCULAR: Regular rate and rhythm, normal S1-S2. No murmur or
gallops could be appreciated.
LUNGS: Clear to auscultation bilaterally. No crackles, wheezings, rhonchi
was appreciated.
ABDOMEN: Normoactive bowel sounds, nondistended, nontender. No
organomegaly.
EXTREMITIES: Less than 1+ pitting edema in both lower extremities. No
clubbing or cyanosis. Has good distal pulses in all four extremities.
INTEGUMENTARY: Intact, no rash.
NEUROLOGIC: Grossly intact with no focal, sensory, or motor deficits.
9
Key Components
• Medical Decision Making
− Number of diagnosis or management
− Amount
A
t and/or
d/ complexity
l it off d
data
t
− Risk of complication
MEDICAL DECISION MAKING
BOX A: Number Of Diagnosis or Management Options (N x P = R)
Problems
Number Points Results
Self-limited or minor (stable, improved or worsening)
Max = 2
1
problem: stable or improved
p
1
Est. p
Est problem: worsening, failing to change
2
New problem: no additional work-up planned
Max = 1
3
New problem: additional work-up planned
4
Bring to line A in Final Result for MDM
Total
Number of Diagnosis / Problems
Impression:
Shortness of breath
Hypertension
Patient is scheduled for pulmonary consult
and started on fast acting albuterol
inhaler. F/U after consult.
10
MEDICAL DECISION MAKING
Points
BOX B: Amount and/or Complexity of Data to be reviewed
Review and/or order of clinical lab test
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtaining history from
someone other than patient
Review and summarization of old records and/or obtaining
history from someone other than patient and/or discussion of
case with another health care provider
Independent visualization, tracing or specimen itself (not simply
review of report)
Bring to line B in Final Result for MDM
1
1
1
1
1
2
2
Total
9 In order to get credit, the provider must document review & summary
9 You do not get 2 points if billing the professional component (-26)
Amount of Data
Chest Pain
Diabetes
Chest X-Ray in the office today was
normal. Patient scheduled for 24-hour
Holter monitor. Also ordered fasting A1C
as patient is overdue.
Low
Minimal
BOX C: Risk of Complication and/or Morbidity or Mortality
Presenting Problems
Diagnostic Procedures ordered
•
Lab tests requiring venipuncture
•
1 self-limited or minor problem
•
EKG/EEG
(eg. Cold, insect bite, tinea
•
Urinalysis
corporis
•
Ultrasound, X-RAYS
•
KOH prep
•
2 or more self-limited or minor
•
Physiologic test not under stress
problems
•
Non-cardiovascular imaging
•
1 stable chronic illness
•
Superficial needle biopsies
•
Clinical lab test requiring arterial puncture
•
Acute uncomplicated illness or
•
Skin biopsies
injury
Moderaate
•
•
•
•
•
High
•
•
•
1 or more chronic illnesses
w/mild exacerbation, progression
or side effects of treatment
2 or more stable chronic illnesses
Undiagnosed new problem w/
uncertain prognosis
Acute illness with systemic
symptoms
Acute complicated injury
1 or more chronic illnesses w/
severe exacerbation,
progression, side effects of
treatment
Acute or chronic illnesses or
injuries that pose a threat to life
or bodily function
Abrupt change in neurologic
status
•
•
•
•
•
•
•
•
•
Management Options Selected
•
Rest
•
Gargles
•
Elastic bandages
•
Superficial dressings
•
•
•
•
•
•
Physiologic test under stress
Diagnostic endoscopies w/no identified risk
factors
•
Deepp needle or incisional biopsy
p y
Cardiovascular imaging studies w/contrast,
no identified risk factors
•
Obtain fluid from body cavity
•
•
•
Cardiovascular imaging studies w/contrast
w/ identified risk factors
Cardiac eletrophysiological tests
Diagnostic endoscopies w/indentified risk
factors
Discography
•
•
•
•
•
Over-the-counter drugs
Minor surgery w/ no identified risk
factors
Physical therapy
Occupational therapy
IV fluids without additives
Minor surgery with identified risk
factors
Elective major surgery w/o risk
((open,
p , percutaneous,
p
, or
endoscopic)
Prescription drug management
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fracture or
dislocation w/o manipulation
Elective major surgery (open,
percutaneous or endoscopic) w/risk
Emergency major surgery (open,
percutaneous or endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive
monitoring for toxicity
Decision not to resuscitate or to deescalate care because of poor
prognosis
11
Risk
Patient presents today with hypertension,
diabetes and hyperthyroidism. Patient
appears stable on current regimen and no
changes are required at this time.
MEDICAL DECISION MAKING
BOX D: Final Result for Complexity of Medical Decision Making: 2 of 3 required
A Number of diagnoses or
≤1
2
3
management options
Minimal
Limited
Multiple
≥4
Extensive
B Amount and complexity of
data to be reviewed
≤1
Minimal
2
Limited
3
Multiple
≥4
Extensive
C Risk of complications and/or
morbidity or mortality
Minimal
Low
Moderate
High
Straight
Forward
Low
Complexity
Moderate
Complexity
High
Complexity
TYPE OF DECISION MAKING
Medical Decision Making
Inguinal Hernia
New Problem, no work up
Diabetes
N t addressed
Not
dd
d
Hypertension
Not addressed
Robert presented today with acute abdominal pain. The ultrasound reveals
a rather large inguinal hernia that will need surgical intervention. We will
schedule him with a general surgeon first thing in the morning.
Review/order ultrasound
Major surgery without complications
12
Medical Decision Making
Sore throat
Established Problem, worsening
Cough
N
New
P
Problem,
bl
no work
k up planned
l
d
Patient returns with continued sore throat. Rapid Strep test done in
the office is negative. New productive cough complicating sore
throat. Patient given prescription for Tusslon pearls 250mg, every 4
hours for the next 24. Will call if symptoms do not improve.
Order/review lab test
Prescription Drug Management
Chief Complaint must
be documented.
HPI
ROS
PFSH
Problem
Focused
Exp. Problem
Focused
Detailed
1-3
1-3
4+
2-9
4+
4+
10+ or
10+ or
“All others “All others
negative”
negative”
None
1
None
None
1
3
3
1
2-7
2-7
w/ 1 in
Detail
8+
Organ
Systems
Only
8+
Organ
Systems
Only
Straight
Forward
Straight
Forward
Low
Moderate
High
99201
99241
99251
99202
99242
99252
99203
99243
99253
99221
99234
99204
99244
99254
99222
99235
99205
99245
99255
99223
99236
Examination
MDM
Comprehensive Comprehensive
Established Patient– Office or Outpatient
Only need 2 out of 3 Key elements in a column to support the code at the bottom.
HPI
1-3
1-3
4+
ROS
None
1
2-9
4+
10+ or
“All others
negative”
PFSH
E
Examination
i ti
None
None
1
2
1
27
2-7
27
2-7
8+
Area or
Organ system
Medical
Decision
Making:
Office Est. pt.
Areas &/or
Areas &/or
Organ systems Organ Systems
1- Detail
Organ
Systems
Only
Straight
Forward
Low
Moderate
High
99212
99213
99214
99215
13
Pages 4-5
2013 CPT
New Versus Established Patients
A new patient is one who has not received any face to
face professional service from the physician/qualified
healthcare professional
or
another physician/qualified healthcare professional of the
exact same specialty/subspecialty who belongs to the
same group practice within the past three years (Check
taxonomy codes if unsure)
™ Medicare regulation states: "Physicians in the same group
practice who are in the same specialty must bill and be
paid as though they were a single physician."
Refer to the CPT “Decision Tree” on page 5 of 2013 CPT Professional
Important E&M Terminology
Page 5
2013 CPT
• Concurrent Care
− The provision of similar services (e.g., hospital visits) to the same patient
by multiple providers on the same date
• Transfer of Care
− The process whereby a provider managing a patient “relinquishes” the
responsibility
ibilit tto another
th provider
id and
d that
th t provider
id explicitly
li itl agrees tto
accept responsibility
• Consultation
− A “request” by one provider for another provider to offer an opinion
and/or advice regarding the management of the patient… “The 3 R’s”
• Time
− Inpatient- Unit/floor time
− Outpatient- Face-to-face time
Office and Other Outpatient Services
• 99201-99205
Pages 11-13
2013 CPT
− New patient visits
− Require all 3 “key” components
− Remember new patients have not received
professional services within previous three (3) years
• 99211-99215
99211 99215
− Established patient visits
− Require 2 of the 3 “key” components
• 99211 is a level of E&M service that typically
does not require the presence of a physician
• Tip: Highlight the time frames and number of
“key” components required for each of the codes
in this section
14
CPT Code 99211
Page 12
2013 CPT
¾Typical nurse visits include, patient education, injections, infusions,
problem focused evaluations and specimen collection.
¾ Per CPT, “Usually, the presenting problem(s) are minimal. Typically,
five minutes are spent performing or supervising these services.”
¾Generall R
¾G
Requirements
i
t
◦ Non – Physician must be:
◦ Employee or contractor for physician
x Follow physician orders resulting from his/her evaluation of the
patient
x Be supervised by a physician
• “Because medical necessity is required, vital signs and blood pressure
checks may not be routinely performed at the time of another coded
service in order to bill for a 99211 visit” (e.g., injections, INRs, etc.)
Observation Services
Pages 13-15
2013 CPT
CPT® Codes 99217-99220 & 99224-99226
•
Reserved for patients designated/admitted as “observation status” in the hospital
•
There are three “levels” for initial observation
−
Observation is a “status”, not a physical location
−
•
99218-99220
• New in 2012: Times are now associated with these codes (30min/50min/70min thresholds)
• Use “unit/floor time” concept
There are three NEW “levels” for subsequent observation
−
#99224-99226 (resequenced)
− 30min/50min/70min thresholds
•
There is one code to report observation discharge
−
99217
Hospital Inpatient Services
Pages 15-17
2013 CPT
• 99221-99223 for initial hospital care (“admits”)
− Defined as the “first hospital inpatient encounter by the admitting physician”
• 99231-99233 for inpatient rounds
− “Clustering” levels of E/M for subsequent hospital visits can be an audit target
(CMS 10/00)
• 99238, 99239 for inpatient discharges
−
You MUST document “>30 minutes” to support 99239
• 99234-99236 for same day admit/discharge
− Same codes as observation but require POS 21
15
Consultation Services
Pages 18-21
2013 CPT
99241-99255
§15506 MEDICARE MANUAL (CMS PUB 14-3)
• The request for consultation must be in writing
• Therapeutic or diagnostic services may be provided during the course of a consultation
• A written report to the requesting physician must be provided (outpatient setting only‘ h d records’)
‘shared
d ’)
• The requesting physician’s NPI goes in box 17b of the CMS 1500 claim form
• Referrals are NOT to be coded as consultations
• CMS placed moratorium on consultation services (1-1-2010)
• The 3 R’s (Request, Render, Respond)
Emergency Department Services
Pages 21-22
2013 CPT
99281-99285
• Only covered for patients registered in the ED of a hospital-based facility (POS 23).
• Any physician that provides services in the ED
–
Do not report ED code if called in to “consult”
• Not required to be an emergency service
• No distinction between new or established patients
• Includes History, Exam, and Decision Making (all 3 required)
• No typical time associated with these codes
Critical Care Services
99291-99292
Pages 23-25
2013 CPT
Critical care: The direct delivery by a physician(s) of
medical care for a critically ill or critically injured patient.
– A critical illness or injury is defined in 2013 CPT®
Professional (page 23) as one that “acutely impairs one or
more vital organ systems such that there is a high
probability of imminent or life threatening deterioration
in the patient’s condition”
– i.e. CNS failure, circulatory failure, shock, renal failure,
etc.
– Time must be documented (suggested to use clock time)
– Time does not need to continuous (may be cumulative per
day)
– For inpatients 0 days through 5yrs, refer to per diem codes
99468-99476 (Neonatal versus Pediatric)
16
Critical Care Services
99291-99292
• Critical care may be provided on multiple days even without a change
in treatment as long as the patient’s condition continues to require a
high complexity decision making.
• For any given period of time spent providing critical care services, the
physician must devote his or her full attention to the patient, and
therefore, cannot provide services to any other patient during the
same period of time.
• See guidelines on pages 23-24 of CPT 2013 Professional
− Same specialty providers are not permitted to report
critical care on same date
− Distinct providers (and diagnoses) are permitted to
report critical care
− When one MD reports “per diem” code, others must
refer to 99291-25
Incident to
• Follow established patient’s on plan of
care already established by physician
• Cannot see new patients and bill
incident to (report under own ID)
• Cannot see established patients for a
NEW problem (report under own ID)
Split / Shared Visits
• Patient is seen by both NPP and MD
possibly at different times
• Each provider documents their
encounter
• Physician can use NPP’s documentation
towards their total encounter level
17
Split / Shared Visits
EXAMPLES OF SHARED VISITS
• 1. If the NPP sees a hospital inpatient in the morning and the
physician follows with a later face-to-face visit with the patient
on the same day, the physician or the NPP may report the
service.
• 2. In an office setting the NPP performs a portion of an E/M
encounter and the physician completes the E/M service. If the
"incident to" requirements are met, the physician reports the
service. If the “incident to” requirements are not met, the
service must be reported using the NPP’s UPIN/PIN.
PATH Guidelines
• Resident documentation
• Attending documentation
− Attestation statement examples
− Time based codes (only attending time)
− Surgical procedures
• Modifier 82 when resident not
available/qualified
Facts Related to Modifier -25
The following statements are false:
− I can always use this modifier for a new patient.
− I can always use this modifier when I did not plan the
procedure.
− I can always use this modifier when the diagnoses are
different.
− I can never use this modifier when the diagnoses are the same.
Appropriate Usage:
• “Modifier 25 indicates that on the day of a procedure, the
patient's condition required a significant, separately identifiable
E/M service, above and beyond the usual pre and post-operative
care associated with the procedure or service performed”
Source: WPS Medicare
18
E/M Modifiers
Modifier 24: Unrelated E/M during global
Modifier 25: E/M with minor procedure
Modifier 32: Mandated Service
Modifier 57: E/M with major procedure
Regan Tyler, CPC, CPC‐H, CPMA, CEMC, ACS‐EM
rtyler@drsmgmt.com 19