Kansas City ACDIS
Chapter
Kansas City CDI Group
ACDIS CHAPTER
POST ICD 10
November 10, 2015
Agenda
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Introductions
Housekeeping Issues:
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CCDS request for CE credit form
Sign in Sheet
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Please complete the online membership roster
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There has been some discussion on tricky ICD-10 items
via CDI Talk if that helps your presentation
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We are seeking donations of ICD-10 query forms for
our Forms & Tools Library. They can email me at
mvarnavas@acdis.org to contribute
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ACDIS recently updated its Code of Ethics. It’s free
and open to the public. We encourage everyone to read it.
Study Group
How Did ICD 10 Go?
• ICD 10….41 Days Post GO-LIVE
• How did everything go? Coding, CDI, Staffing, Auditing,
Training physicians
• Challenges?
• Documentation Issues
• Tips for Queries for ICD 10
• Specific Examples
• To update your information on ACDIS website for our group go
to:
• http://www.keysurvey.com/votingmodule/s180/f/617822/c7f0/
CORONARY ARTERY
INTERVENTION SITE (ICD-10-PCS)
• With ICD-10-PCS, the treatment of coronary
arteries has changed. Coronary arteries are
classified as a single body part that is further
specified by number of sites treated, not by name
or number of arteries (B4.4).
• So the question remains, what is a “site”? A
coronary intervention “site” refers to each distinct
lesion treated, unless a single lesion extends into
more than one artery. (CC 2Q2015 p.3)
CORONARY ARTERY
INTERVENTION SITE (ICD-10PCS)
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Coding Clinic has received multiple questions about what
constitutes a “site”, and they posted five examples of what a
“site” is. Here is the breakdown:
1. Multiple drug-eluting stents placed in multiple
coronary artery lesions. In this example, the patient had
DES placed in three separate arteries, and this is
considered three coronary artery sites. (CC 2Q2015 p.3)
2. Multiple stents to treat single coronary artery lesion. In
this example, the patient had one long lesion of an artery,
and had two stents placed. Since it was the same lesion,
it is considered ONE site. (CC 2Q2015 p.3-4)
CORONARY ARTERY
INTERVENTION SITE (ICD-10-PCS)
• 3. PTCA of one coronary artery with more than one
lesion, DES. In this example, the patient had two
lesions, both in the same artery, but one was at the
proximal left anterior descending, and one was at
the distal left anterior descending artery. Since
they were two separate lesions, this is considered
two coronary sites. (CC 2Q2015 p.4)
• 4. Treatment for coronary artery lesion extending
into bifurcation. In this example, the lesion that was
within the left anterior descending coronary artery
extended into the branch artery of the LAD at the
bifurcation, and two stents were placed. This is
coded as one site, bifurcation, with DES, since it
was one lesion that extended to the branch.(CC
2Q2015 p.4-5)
CORONARY ARTERY
INTERVENTION SITE (ICD-10-PCS)
• Treatment for two distinct lesions in the same
coronary artery. In this example, the patient had
PTCA of the right coronary artery (RCA) with
placement of two drug-eluting stents, and also
had PTCA of the proximal and mid-portion of the
left anterior descending (LAD) coronary artery.
Three drug-eluting stents overlapping from the
proximal to the mid- LAD were inserted. This is
coded to two sites, because they treated the site
in the RCA with two stents, and the site in the
proximal-mid LAD with three stents. These are
considered “long lesions” or a single site each
(one site RCA one site LAD).(CC 2Q2015 p.5)
CORONARY ARTERY
INTERVENTION SITE
(ICD-10-PCS)
ICD 10 PCS
Interventional Radiology
• This patient had a thrombomechanical
thrombolysis of the ileofemoral popliteal
viens. But there isn’t specificity as to which iliel
vein, femoral vein was treated.
• Femoral vein does include the popliteal vein, but
the iliac is the true problem, do we just assume
that it would be in the external iliac vein?
• http://www.healthline.com/human-bodymaps/common-iliac-vein.
ICD 10 PCS Interventional Radiology
ICD 10 PCS Interventional Radiology
ARTIFICIAL RUPTURE OF
MEMBRANES (ICD-10-PCS)
• In ICD-9, coders were instructed to only code
artificial rupture of membranes (AROM) if it
was performed to induce labor. It was not to be
coded if it was performed to augment labor.
• The instruction in ICD-10-PCS has changed.
Artificial rupture of membranes should be
coded when it is performed to induce or
augment labor. The following information is
from Coding Clinic:
• There is also a 3m Nosology Help Message
Leadless pacemaker insertion
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Coding Clinic, Second Quarter ICD-10 2015 Pages: 31-32 Effective
with discharges: July 6, 2015
Question:
A 70-year-old male with first and second degree atrioventricular (AV)
blocks as well as right bundle branch block presents for insertion of
a leadless pacemaker. A leadless pacemaker was inserted via
catheter under fluoroscopic guidance into the right ventricle. The
ICD-10-PCS does not provide a value for leadless pacemaker. How
should this procedure be coded?
Answer:
The ICD-10-PCS does not provide a specific device value for
leadless pacemaker. Intraluminal device is the closest available
equivalent. Assign the following ICD-10-PCS code for this new
technology:
02HK3DZ
Insertion of intraluminal device into right ventricle, percutaneous
approach
Excludes1
• The Centers for Disease Control (CDC) has
received many inquires regarding
interpretation of the Excludes1 note
regarding diagnoses unrelated to one
another where an Excludes1 note is
included in the tabular list. Below is the
interim guidance by the CDC to help with
interpreting the Excludes1 Notes:
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If the two conditions are not related to
one another, it is permissible to report
both codes despite the presence of an
Excludes1 note.
Excludes
The Excludes1 note at code range R40-R46, states that symptoms and
signs constituting part of a pattern of mental disorder (F01-F99) cannot be
assigned with the R40-R46 codes. However, if dizziness (R42) is not a
component of the mental health condition (e.g., dizziness is unrelated to
bipolar disorder), then separate codes may be assigned for both
dizziness and bipolar disorder.
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In another example, code range I60-I69 (Cerebrovascular Diseases)
has an Excludes1 note for traumatic intracranial hemorrhage (S06.-).
Codes in I60-I69 should not be used for a diagnosis of traumatic
intracranial hemorrhage. However, if the patient has both a current
traumatic intracranial hemorrhage and sequela from a previous stroke,
then it would be appropriate to assign both a code from S06- and I69-.
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This information can also be found at:
http://www.cdc.gov/nchs/data/icd/Interim_Coding_advice_on_Excludes_1
_note.pdf
Problem solving Scenarios
• Case Study #1
– St Elsewhere’s Compliance
Department analyzed accounts for OctDec 2015 and determined 50% of their
principal diagnoses were submitted as
“unspecified”.
• What would the internal audit objective be?
• What data elements would be most useful
to determine problem resolution?
Problem solving
Scenarios
Case Study 2: Your facility has an
increased of Observed vs. Expected
Mortality on patients with Sepsis? Your
CFO wants an analysis and a plan for
improvement.
What data would you gather? What would
you want to look at.
Who would you include on your team?
What data would you get from CDI?
Problem solving Scenarios
CASE Study #2 cont.
Is Severe Sepsis Present
• In order to say yes by CMS specs, it has to be either
documented by physician preferably in the ED record OR 3
criteria has to be met within 6 hours each other.
– Documentation of suspected source of clinical infection
– 2 or more of SIRS criteria: Temp .38.3 C or <36.0 C,
HR>90, RR>20 and WBC>12,000 or <4,000 or >10%
bands
– Organ dysfunction evidenced by any one of the following:
SBP<90 or MAP<65 or SBP decrease of more than 40
points
Crt >2.0 or urine output <0.5ml/kg/hr for 2 hours
Bili >2 mg/dl
Plt <100,00
INR > 1.5 or aPTT >60 sec
Lactate > 2mmol/L
Problem solving
Scenarios
CASE Study #2 cont.
• 45 y/o female arrived to ED on 3/17 at 1330,
complaining about SOA for the last 2 weeks. History
of DM, CAD, valvular disease, Hypertension, ESRD
with Hemodialysis on M/W/F, and diabetic foot ulcers.
• ER physician exam revealed black/necrotic toes with
foul odor. CXR unrevealing. Clinical impression
dyspnea on exertion and necrotic toes.
• Labs essentially normal with baseline elevated Crt of
7.2, WBC was 8.49. Initial vitals 98.6 F, HR 97, RR
16, and BP 98/52. Admitted to Med/Obs.
Problem solving Scenarios
CASE Study #2 cont.
• On morning of 3/18 pt began having decreasing
blood pressures with SBP below 90 several times.
Blood cultures obtained along with UA micro. 500
cc NS bolus given.
• Pt officially met severe sepsis criteria 3/18 @
1219 with vital of: HR=109, RR=22, and BP
86/42. Rest of day stayed in Med/Obs, no abx
ordered, again received some fluid boluses.
DRG Changes
Two new Endovascular Cardiac Valve Replacement
DRGs are carved out from the current DRGs 216221 to distinguish such patients from Open Valve
Replacement:
• DRG 266 - Endovascular Cardiac Valve
Replacement with MCC
• DRG 267 - Endovascular Cardiac Valve
Replacement without MCC
DRGs 483 and 484 - Major Joint/Limb Reattachment
of Upper Extremity with and without CC/MCC are
combined into a single DRG:
• DRG 483 - Major Joint/Limb Reattachment of
Upper Extremity
Aneurysm Repair
• For this aneurysm repair, we would go with the root
operation “repair”, which is “restoring to the extent
possible, a body part, to its normal anatomical
structure and function. They did not put in graft
material.
• So the best code for the repair of the aneurysm
would be 04QF0ZZ, repair left internal iliac artery,
open approach.
• You would also have B41G1ZZ for the fluroscopy of
the left lower extremity arteries using low osmolar
contrast-for the angiography that was done on 9/29
Open or Percutaneous?
The valve was placed transcatheter, not open.
It's not a full blown sternotomy with rib spreaders,
etc.
They would not jam the catheter with the valve
through the skin and ribs; they need to make a
percutaneous incision to assist getting the materials
through.
Going back to the definition of open: cutting
through skin...to expose the site of the procedure.
TAVRs do not expose the site of the procedure.
MEDIASTINAL LYMPH NODE LEVELS
MEDIASTINAL LYMPH NODE
LEVELS
• CONTINUED: MEDIASTINAL LYMPH NODE
LEVELS
• Definition of nodal zone and nodal station: A
nodal zone is an anatomical area that includes
one or several neighboring nodal stations.
• The supraclavicular and the subcrainal zones
include one nodal station each (station 1 & station
7). The other nodal zones include two, three or
six nodal stations. It is important to realize that, in
theory, a single N2 zone may have from one to
multiple nodes involved in one or several nodal
stations, and the nodes may be small or large.
MEDIASTINAL LYMPH
NODE LEVELS
• The concept of nodal zones is of special
value for those patients who will not
undergo surgical treatment. For those
receiving chemotherapy, radiotherapy or
the combination of the two, the precise
anatomical location of the nodes involved
is not so important. The nodal zones help
locate nodal involvement without having to
define the exact anatomical location of the
nodes.
MEDIASTINAL LYMPH
NODE LEVELS
• However, nodal stations are important for those patients in
whom surgical treatment is required. Precise nodal
location is important preoperatively to guide surgical
treatment, and also intra- and postoperatively to indicate
further treatment. This is especially relevant in the upper
mediastinal zone. Whether the right or the left
paratracheal nodes are involved or not is important to
confirm or rule out N2 or N3 disease and to select patients
for surgical (multimodality) treatment.
• If a physician removes all nodes in a zone, the root
operation is resection. If a physician does not remove all
nodes in a zone, the root operation is excision.
Debridement
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Debridement documentation for ICD-9
required the depth of tissue debrided and to
specify, by using the word “excisional,” if the
procedure was excisional. According to
Coding Clinic 1st quarter of 2008, this was
needed even when the description of “sharply
debrided” was used. Though depth into
tissue is still required, thankfully, ICD-10-PCS
documentation requirements of use of the
word “excisional” have relaxed somewhat.
Over the years there was much Coding Clinic
advice given.
Debridement
Among their most recent, first quarter 2013,
stated that the coder cannot assume that
debridement is excisional so documentation
of the type is necessary. ICD-10-PCS
requests the type of procedure or technique
used to be stated. If the procedure is
described as a “cutting out” or “cutting off”
and there is no replacement, then the actual
word “excisional” is no longer required. ICD10-PCS documentation requirements are
more closely aligned to CPT documentation
needs so that the Clinical Documentation
Specialist (CDS) and coder should attain
increased provider cooperation with ICD-10PCS of debridement documentation needs.
• CPT; Type of debridement:
• Excision-Surgical removal of tissue at
wound margin or at the wound base
until viable tissue is achieved.
Explaining the technique used and by
naming the instrument used will help
support any questionable
documentation and would be
defendable from overzealous auditors.
If the technique is not excisional, the
method used likewise needs to be
mentioned.
The coder should be able to discern
the root operation performed by the
procedure note and not simply
dependent upon a certain word used.
Debridement
• ICD-10 PCS Official Guidelines, Section
A11
• “Many of the terms used to construct PCS
codes are defined within the system. It is
the coder’s responsibility to determine
what the documentation in the medical
record equates to in the PCS definitions.
The physician is not expected to use the
terms used in PCS code descriptions, nor
is the coder required to query the physician
when the correlation between the
documentation and the defined PCS terms
is clear.
Hepatic
Encephalopathy
• Is hepatic encephalopathy and hepatic coma
one in the same? It seems as if we will need
the physician to specifically document
"hepatic coma" when applicable as the
encephalopathy terminology alone does not
get us there. The difference between these
two codes will be an MCC versus No MCC.
The potential difference here for DRG
payers is massive if the coding changes and
we cannot assume that encephalopathy
always means coma.
Hepatic Encephalopathy
Due to Viral Hepatitis
Coding Clinic, Second Quarter 2007 Page: 6
Effective with Discharges: June 30, 2007
Question:
When assigning the code for viral hepatitis with
encephalopathy, is code 572.2, Hepatic coma,
assigned as an additional code, or is this information
captured in category 070, Viral hepatitis at the fourth
digit level, which describes "with hepatic coma"?
What is the correct code assignment for hepatic
encephalopathy due to a specific type of viral hepatitis?
Hepatic
Encephalopathy
• Answer:
Assign the appropriate code from category 070, Viral
hepatitis, with the fourth digit indicating hepatic coma,
for the viral hepatitis with hepatic encephalopathy. The
hepatic encephalopathy (coma) is included in the code
assignment at the fourth digit level, so it is not
necessary to report 572.2, Hepatic coma, as an
additional code assignment.
If you look at the descriptors in the K72 series, it
includes the term hepatic encephalopathy with the
coma term. All is well, MCC or not. The docs don't
have to change anything.
Encephalopathy
• Encephalopathy and coma are synonyms in
ICD (9 or 10) as stated...". Is there
something in ICD 10, that states they are
synonymous? And/or CAN we use Coding
Clinics from ICD 9 until the topics are
addressed in ICD 10?
Also your statement - "If you look at the
descriptors in the K72 series, it includes the
term hepatic encephalopathy with the coma
term ... The docs don't have to change
anything". Again, I am not sure where that
comes from. My resources state:
Encephalopathy
• K72- Hepatic failure, not elsewhere classified
Includes:
acute hepatitis NEC, with hepatic failure
fulminant hepatitis NEC, with hepatic failure
hepatic encephalopathy NOS
liver (cell) necrosis with hepatic failure
malignant hepatitis NEC, with hepatic failure
yellow liver atrophy or dystrophy
K72.91 Hepatic failure, unspecified with coma
Inclusion Term:
Hepatic coma NOS
• K72.0 Acute and subacute hepatic
failure
K72.00 Acute and subacute hepatic
failure without coma
K72.01 Acute and subacute hepatic
failure with coma
K72.1 Chronic hepatic failure
K72.10 Chronic hepatic failure without
coma
K72.11 Chronic hepatic failure with
coma
So, basically you add your inclusions to
get the specifics of the acute or subacute
process and you have the with and
without coma.
With the acute hepatitis codes, we have:
B15 Acute hepatitis A
B15.0 Hepatitis A with hepatic coma
B15.9 Hepatitis A without hepatic coma
Hepatitis A (acute)(viral) NOS
B16 Acute hepatitis B
B16.0 Acute hepatitis B with delta-agent with hepatic coma
B16.1 Acute hepatitis B with delta-agent without hepatic coma
B16.2 Acute hepatitis B without delta-agent with hepatic coma
B16.9 Acute hepatitis B without delta-agent and without hepatic
coma
So it's the same thing - with and without "hepatic coma."
Now, is hepatic coma the same as hepatic encephalopathy? Whether
it says it now in Coding Clinic for ICD-10 or not, that is the definition.
Hepatic coma is a metabolic encephalopathy caused by elevated
bilirubin levels.
Lessons Learned
•3M Encoder had some issues
•Interface Issues
•Didn ‘t anticipate challenges with new coding
tables
•Increase in query for specificity
•Some of the procedural pathways lead to different
codes. Careful on the choices you pick in the
encoder.
•Codes may put some cases into a HAC
depending on the documentation.
•New challenges for documentation
Post Implementation Issues
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Coder productivity
Number of concurrent queries
Number of concurrent queries
Days to final bill
Pre-authorization
Claim edits and denials
Days to payment
Coder questions
Coding quality
Revenue cycle flow
. Number of concurrent queries. Most of us can assume
queries will increase due to the more specific nature of ICD10, especially with ICD-10-PCS. The worst-case scenario is
that queries will double or even triple in volume.
Hopefully, organizations have already begun to ask for
clinical details necessary in ICD-10, thereby mitigating the
increase in queries post go-live. Regardless, it's important to
monitor the concurrent query volume and compare it with
your baseline. Following are three questions to ask:
•Are queries increasing significantly? If so, are these queries
related to a particular service line or provider
•Can you work with a physician advisor to perform physician
education in those areas causing query spikes
•Can you use templates to collect additional documentation
electronically or automatically?
Coder productivity
Many experts agree that coder productivity will take an initial
hit by as much as 50 percent. Organizations should know
exact coder productivity in ICD-9 in order to monitor their
decrease. The productivity drop will likely vary from institution
to institution, depending on the quality of coder training and
physician documentation.
HIM directors should expect an initial dip followed by a
gradual increase. If a gradual increase isn't apparent, take
corrective steps immediately by asking three critical
questions:
•Is additional coder education necessary? In what specific
areas?
•Are documentation gaps causing productivity lags? What
CDI interventions can be immediately performed?
•What are the factors that slow coders down, and how can
you address those factors to put coder productivity back on
the upswing?
Number of concurrent queries. For retrospective
queries, it is important to know your baseline in ICD9 and then compare the volume of retrospective
queries in ICD-10. An increased number of
retrospective queries could indicate a breakdown in
communication between CDI or coders and
physicians.
Another reason for lackluster physician response to
retrospective queries may be ICD-10 overload and
the surge in queries. Be attuned to process and
workflow improvements that may help alleviate
query overload for physicians. In addition, consider
implementing a process to prioritize queries.
Days to final bill
What is the organization's average discharged not final billed
(DNFB) in ICD-9, and what does the DNFB look like immediately
following ICD-10? A rising DNFB could indicate a problem with
insufficient physician documentation, a lack of physician
responses to queries, coder problems with ICD-10 code
assignment, technological glitches, and more. The goal is to
identify the cause of coding delays so coders don't fall further
and further behind during a time when productivity is already
compromised.
. Pre-authorization
Obtaining prior authorization for services is often a
necessary prerequisite for payment, which makes it a highrisk area in ICD-10. In particular, organizations must ensure
that orders and referrals from physician practices include
ICD-10 codes. These codes must also be as specific as
possible.
Be prepared to provide additional support for staff members
who obtain prior authorizations from physician practices.
Many HIM professionals fear that physician practices will
continue to submit ICD-9 codes even though the industry
has—for the most part—transitioned to ICD-10. Reach out to
practices proactively to ensure they have a plan in place to
submit correct ICD-10 information.
Claim edits and denials
Be on the lookout for payment impacts sometime in
mid to late October, depending on your organization's
accounts receivable cycle. Track and trend payer
responses, including specific edits and medical
necessity denials. What types of edits occur and how
often? Incorporate this information into a go-forward
mitigation strategy.
Coding quality
Select high-risk cases to audit as well as cases for
which there is a diagnosis-related group (DRG)
shift between ICD-9 and ICD-10. Ideally, coding
educators can audit these cases prior to
submission, although even retrospective audits are
helpful. The idea is to identify a pattern of incorrect
coding before third-party auditors do.
Coder questions. Although the American
Hospital Association's Coding Clinic continues to
provide ICD-10 guidance, many coder questions
are expected immediately following go-live.
Organizations must establish a method whereby
coders can submit questions internally to a
dedicated individual for compilation of concerns
to Coding Clinic and tracking of responses.
Failure to monitor this information will create
rework and inconsistent coding within the
department.
Revenue cycle flow
Follow the entire flow for each record
type—inpatient, outpatient, same-day
surgery, emergency department, and
recurring accounts—including Medicare
and commercial cases. Did the record
move through scheduling and preauthorization to coding/billing and then
to the payer? This information can be
tracked within the first ten days following
go-live.
On-going Monitoring
• Perhaps the greatest indicator of organization-wide
performance is the case mix index (CMI). Barring any
seasonal changes, clinical personnel changes, or service line
changes, the CMI shouldn't increase or decrease significantly
after go-live. Monitor the CMI closely, as a change could
indicate a deeper problem with coding and/or documentation.
• As with all performance metrics, the goal is to identify
problems when they're still relatively small and manageable.
The metrics discussed in this article are those that require
close monitoring in the days immediately following
implementation; however, there are many more metrics to
monitor on an ongoing basis. HIM can help drive process
improvement by keeping tabs on this information and regularly
sharing it with hospital executives
Claims Operations Testing
• We have tested hospital ICD-10 claims processes with our
clearinghouse and the following payors with no issues:
RelayHealth
Medicare
MO Medicaid
TriCare
Cigna
BCBS – Kansas City
Humana
BCBS – Kansas
• Our workers compensation payors will also accept ICD-10
• Clinics completed claims submission testing in the Epic
environment (live in the clinics 8/1/15)
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Resource Prioritization & Contingency
Plans
Contract Coding Support
• Participated in evaluation and selection of two coding vendors.
We have contracted with TrustHCS and are using 15 – 17
coders, mitigating AR increases.
– This represents a 50% increase in coding resources over internal staff
– That amount represents the projection for coder productivity loss immediately
after go-live.
Epic Tools
• We have leveraged Epic implementation to include activation
of “Diagnosis Calculator” technology to assist physicians with
a decision tree to arrive at ICD-10 required documentation
specificity of diagnosis codes.
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HIM/Coding
• Facility based coders went through over
50 hours of education.
• Facility based coders began doublecoding accounts in June 2015.
• Our metro hospital revenue cycle system
is successfully passing both ICD-9 and
ICD-10 codes to downstream
applications including Quality and
Decision Support.
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HIM/Coding
• Facility based coders went through over
50 hours of education.
• Facility based coders began doublecoding accounts in June 2015.
• Our metro hospital revenue cycle system
is successfully passing both ICD-9 and
ICD-10 codes to downstream
applications including Quality and
Decision Support.
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Education Key Audiences
• Providers: Provider education has been
occurring since 2012 when CDI was expanded.
It has continued through Kaizen events, Epic
Best Practice Alerts, and Epic Diagnosis
Calculator. Formal on-line ICD-10 training is
offerred.
• Coders: Hospital coders had ICD-10 training in
2013-2014 with refreshers & quizzes in 2015.
Double coding has been reinforcing that
education and providing real-time opportunities
for on the job training. Clinics organized ICD10 “boot camp” coder training.
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Education
This is an example of a
disease-specific ICD-10 tip
sheet. We have 125 of
these available.
Note that it discusses the
documentation that is needed
and not the codes
themselves.
Our CDI staff are utilizing
these same educational
documents with physicians
as well as asking the same
question content in queries to
the physicians that are
concurrent with patient stay.
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Post Go-Live SWAT
Team Organization
The ICD-10 Steering Committee continues to function as the
vehicle to communicate, discuss, and resolve issues and
barriers post go-live.
“SWAT” Teams are in place to address potential issues such as:
Increase in unbilled claims
Increased denials
Gaps in payments vs. expected payments
Changes in claims processing cycle times
IT system issues
Other unfavorable trends in KPIs
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Monitoring: Key
Performance Indicators
– Denials
– Case mix index
– Coding quality and productivity
– Unbilled account days and dollars
– Average time from claim to payment
– Expected payment variances
– Education completion
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Saint Luke’s
“SWAT” Teams have been in place since 10/01/15
No significant variances from the norm in the key
performance indicators
A handful of minor application and/or interface issues,
most remediated already
Claim payments received to date are appropriate
2184 total staff have been trained
7312 courses have been taken
Of those, 418 were Medical Staff, who have taken 1170
courses
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THANK YOU!