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Get the facts on spinal fusion, instrumentation, and grafts
Editor’s note: This is the second article in a two-part series on spinal surgery coding. In this article, we will focus on fusions, instrumentation, and spinal grafts. In part one, we introduced the basic elements of a spinal surgery and took a closer look at decompression procedures.
A surgeon performs an arthrodesis of lumbar vertebrae L1–L2. What are the appropriate codes to report for this procedure? Would it be CPT® code 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) or code 22612 and add-on code 22614 (each additional vertebral segment)?
A surgeon performing an arthrodesis fuses two bones together to stabilize the spinal motion unit. It is not possible to fuse a bone to itself, says Kim Pollock, RN, MBA, CPC, consultant and speaker with Karen Zupko & Associates, Inc., in Chicago. The least a surgeon can do is fuse one segment to another.
Here’s where the disconnect between code descriptions and the terminology surgeons use comes into play. Two vertebrae and the tissues that connect them make up the smallest working unit of the spine. This unit is sometimes referred to as a spinal motion unit. To a spinal surgeon, a segment is two movable units. To a coder, a segment indicates one bone.
So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612.
Take into account the reason for the fusion
When coding a spinal fusion, consider the reason for the procedure. Review the documentation to determine whether the physician performed the fusion for deformity, pain, or instability, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for The Coding Network based in Beverly Hills, CA.
For a fusion for spinal deformity (e.g., scoliosis or kyphosis), coders should look to codes 22800–22819. This code series was created for, and intended to be used for, fusion procedures performed on younger patients with congenital spinal deformities, not for degenerative scoliosis, says Stumpf.
If the surgeon is performing the fusion for pain or instability, coders should reference one of the following code series:
- 22532–22534 (lateral extracavitary)
- 22548–22585 (anterior or anterolateral)
- 22590–22632 (posterior)
Identify the approach used in the procedure
Surgeons can use various approaches when performing a spinal fusion. Carefully read the documentation to find which approach the surgeon used, then choose the code that reflects that approach. Consider the following approaches:
- Lateral extracavitary (codes 22532–22534)
- Anterior or anterolateral (codes 22558–22585, 22808–22812)
- Posterior or posterolateral or lateral transverse process (codes 22590–22632, 22800– 22804
"Keep in mind that each of these approaches is coded with a different series of codes,” Stumpf says. “You need to understand your approaches. If you don’t, take time to pull them up on the web and see what structures [the surgeon] would be going through, so you can tell exactly what the approach is.” If all else fails, query the physician.
Also note that if the physician documents “direct lateral approach” for spinal fusion, coders should code it as an anterior approach per the North American Spinal Society and the American Association of Neurological Surgeons.
Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of the fusion procedure. Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biomechanical device, such as:
- Polyether ether ketone (PEEK) devices (e.g., Mosaic, LDR, GraftCage, Capstone, Zero-P, STALIF, Solitaire)
- HARMS cage
- BAK cage
- Methylmethacrylate (i.e., bone cement)
Report the application of the above listed intervertebral biomechanical device(s) using add-on code 22851. Note that coders should report code 22851 per interspace or vertebral defect, not per device, says Pollock. Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace.
Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders should report it using code 22851, Stumpf says. Report all structural allografts using code 20931, so they need to pay careful attention to what the device is made of in order to bill biomechanical devices correctly, says Stumpf.
Consider the type of bone graft
Allograft is bone obtained from a donor—not from the patient (i.e., autograft). An allograft bone contains no living cells. Think of an allograft as bone in a bottle or a package. Coders should report all bone graft codes only once per surgery with, Pollock says.
The bone graft codes include:
- 20930 (allograft or osteopromotive material for spine surgery, morselized)
- 20931 (allograft for spine surgery, structural)
- 20936 (autograft, local)
- 20937 (harvest of graft through separate skin incision, commonly iliac crest)
- 20938 (autograft, structural, bicortical, or tricortical)
Coders should only report each bone graft code performed only once per operative session.
Bear in mind other factors
Once coders locate the fusion, instrumentation, grafts, and decompression if the physician performed it, they need to look for some additional elements.
Look to see whether the surgeon used a microscope for microdissection or microsurgical techniques. But note that some carriers—Medicare and private payers who follow Medicare guidelines—will not pay for the use of a microscope, Stumpf says.
However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Coding Initiative (NCCI) edits, she says. CPT guidelines instruct coders to report the microscope use, and CPT lists specific codes with which it should not be reported. However, NCCI edits bundle the microscope into the procedure code.
To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says.
Also remember that CPT guidelines do not prohibit coders from reporting the use of a microscope for a discectomy or laminectomy, Pollock adds. Coders should report the use of the microscope even when the payer won’t reimburse for it because it is an appropriate CPT combination.
Medicare also sometimes reverses the NCCI edits, Pollock adds. “If you didn’t bill for it originally, you won’t be able to file for a redetermination.”
When the surgeon uses a microscope for microdissection, report CPT add-on code 69990 (use of operating microscope) separately in addition to the code for the primary procedure.
When coding for the microscope used for microdissection or microsurgical techniques, coders need to see documentation of the work involved in bringing the microscope into the field, leaving the field, and during the procedure, Stumpf says. The same holds true for the use of stereotactic navigation. The provider needs to set up, use, and document the use of the instrumentation to support the coding.
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at email@example.com.
Interested in learning more about spinal coding? Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services and Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for the The Coding Network based in Beverly Hills, CA, discuss ICD-9-CM and CPT coding for spinal procedures during HCPro’s July 28 audio conference, “Spinal ICD-9 and CPT Coding: Get the Complete Picture for Accurate Reimbursement”. To learn more or to purchase, go to the HCMarketplace Web site. |
|Classification and external resources|
Oxygen toxicity is a condition resulting from the harmful effects of breathing molecular oxygen (O
2) at elevated partial pressures. It is also known as oxygen toxicity syndrome, oxygen intoxication, and oxygen poisoning. Historically, the central nervous system condition was called the Paul Bert effect, and the pulmonary condition the Lorrain Smith effect, after the researchers who pioneered its discovery and description in the late 19th century. Severe cases can result in cell damage and death, with effects most often seen in the central nervous system, lungs and eyes. Oxygen toxicity is a concern for underwater divers, those on high concentrations of supplemental oxygen (particularly premature babies), and those undergoing hyperbaric oxygen therapy.
The result of breathing elevated partial pressures of oxygen is hyperoxia, an excess of oxygen in body tissues. The body is affected in different ways depending on the type of exposure. Central nervous system toxicity is caused by short exposure to high partial pressures of oxygen at greater than atmospheric pressure. Pulmonary and ocular toxicity result from longer exposure to elevated oxygen levels at normal pressure. Symptoms may include disorientation, breathing problems, and vision changes such as myopia. Prolonged exposure to above-normal oxygen partial pressures, or shorter exposures to very high partial pressures, can cause oxidative damage to cell membranes, the collapse of the alveoli in the lungs, retinal detachment, and seizures. Oxygen toxicity is managed by reducing the exposure to elevated oxygen levels. Studies show that, in the long term, a robust recovery from most types of oxygen toxicity is possible.
Protocols for avoidance of hyperoxia exist in fields where oxygen is breathed at higher-than-normal partial pressures, including underwater diving using compressed breathing gases, hyperbaric medicine, neonatal care and human spaceflight. These protocols have resulted in the increasing rarity of seizures due to oxygen toxicity, with pulmonary and ocular damage being mainly confined to the problems of managing premature infants.
In recent years, oxygen has become available for recreational use in oxygen bars. The US Food and Drug Administration has warned those suffering from problems such as heart or lung disease not to use oxygen bars. Scuba divers use breathing gases containing up to 100% oxygen, and should have specific training in using such gases.
- 1 Classification
- 2 Signs and symptoms
- 3 Causes
- 4 Mechanism
- 5 Diagnosis
- 6 Prevention
- 7 Management
- 8 Prognosis
- 9 Epidemiology
- 10 History
- 11 Society and culture
- 12 See also
- 13 References
- 14 Sources
- 15 Further reading
- 16 External links
- Central nervous system, characterised by convulsions followed by unconsciousness, occurring under hyperbaric conditions;
- Pulmonary (lungs), characterised by difficulty in breathing and pain within the chest, occurring when breathing elevated pressures of oxygen for extended periods;
- Ocular (retinopathic conditions), characterised by alterations to the eyes, occurring when breathing elevated pressures of oxygen for extended periods.
Central nervous system oxygen toxicity can cause seizures, brief periods of rigidity followed by convulsions and unconsciousness, and is of concern to divers who encounter greater than atmospheric pressures. Pulmonary oxygen toxicity results in damage to the lungs, causing pain and difficulty in breathing. Oxidative damage to the eye may lead to myopia or partial detachment of the retina. Pulmonary and ocular damage are most likely to occur when supplemental oxygen is administered as part of a treatment, particularly to newborn infants, but are also a concern during hyperbaric oxygen therapy.
Oxidative damage may occur in any cell in the body but the effects on the three most susceptible organs will be the primary concern. It may also be implicated in red blood cell destruction (haemolysis), damage to liver (hepatic), heart (myocardial), endocrine glands (adrenal, gonads, and thyroid), or kidneys (renal), and general damage to cells.
In unusual circumstances, effects on other tissues may be observed: it is suspected that during spaceflight, high oxygen concentrations may contribute to bone damage. Hyperoxia can also indirectly cause carbon dioxide narcosis in patients with lung ailments such as chronic obstructive pulmonary disease or with central respiratory depression. Hyperventilation of atmospheric air at atmospheric pressures does not cause oxygen toxicity, because sea-level air a has a partial pressure of oxygen (ppO
2) of 0.21 bar (21 kPa) and the lower limit for toxicity is more than 0.3 bar (30 kPa).
Signs and symptoms
|Exposure (mins.)||Num. of Subjects||Symptoms|
|96||1||Prolonged dazzle; severe spasmodic vomiting|
|60–69||3||Severe lip-twitching; Euphoria; Nausea and vertigo; arm twitch|
|50–55||4||Severe lip-twitching; Dazzle; Blubbering of lips; fell asleep; Dazed|
|31–35||4||Nausea, vertigo, lip-twitching; Convulsed|
|21–30||6||Convulsed; Drowsiness; Severe lip-twitching; epigastric aura; twitch L arm; amnesia|
|16–20||8||Convulsed; Vertigo and severe lip twitching; epigastric aura; spasmodic respiration;|
|11–15||4||Inspiratory predominance; lip-twitching and syncope; Nausea and confusion|
|6–10||6||Dazed and lip-twitching; paraesthesiae; vertigo; "Diaphragmatic spasm"; Severe nausea|
Central nervous system
Central nervous system oxygen toxicity manifests as symptoms such as visual changes (especially tunnel vision), ringing in the ears (tinnitus), nausea, twitching (especially of the face), irritability (personality changes, anxiety, confusion, etc.), and dizziness. This may be followed by a tonic–clonic seizure consisting of two phases: intense muscle contraction occurs for several seconds (tonic); followed by rapid spasms of alternate muscle relaxation and contraction producing convulsive jerking (clonic). The seizure ends with a period of unconsciousness (the postictal state). The onset of seizure depends upon the partial pressure of oxygen (ppO
2) in the breathing gas and exposure duration. However, exposure time before onset is unpredictable, as tests have shown a wide variation, both amongst individuals, and in the same individual from day to day. In addition, many external factors, such as underwater immersion, exposure to cold, and exercise will decrease the time to onset of central nervous system symptoms. Decrease of tolerance is closely linked to retention of carbon dioxide. Other factors, such as darkness and caffeine, increase tolerance in test animals, but these effects have not been proven in humans.
Pulmonary toxicity symptoms result from an inflammation that starts in the airways leading to the lungs and then spreads into the lungs (tracheobronchial tree). The symptoms appear in the upper chest region (substernal and carinal regions). This begins as a mild tickle on inhalation and progresses to frequent coughing. If breathing elevated partial pressures of oxygen is not discontinued, patients experience a mild burning on inhalation along with uncontrollable coughing and occasional shortness of breath (dyspnoea). Physical findings related to pulmonary toxicity have included bubbling sounds heard through a stethoscope (bubbling rales), fever, and increased blood flow to the lining of the nose (hyperaemia of the nasal mucosa). The radiological finding from the lungs shows inflammation and swelling (pulmonary oedema). Pulmonary function measurements are reduced, as noted by a reduction in the amount of air that the lungs can hold (vital capacity) and changes in expiratory function and lung elasticity. Tests in animals have indicated a variation in tolerance similar to that found in central nervous system toxicity, as well as significant variations between species. When the exposure to oxygen above 0.5 bar (50 kPa) is intermittent, it permits the lungs to recover and delays the onset of toxicity.
In premature babies, signs of damage to the eye (retinopathy of prematurity, or ROP) are observed via an ophthalmoscope as a demarcation between the vascularised and non-vascularised regions of an infant's retina. The degree of this demarcation is used to designate four stages: (I) the demarcation is a line; (II) the demarcation becomes a ridge; (III) growth of new blood vessels occurs around the ridge; (IV) the retina begins to detach from the inner wall of the eye (choroid).
Oxygen toxicity is caused by exposure to oxygen at partial pressures greater than those to which the body is normally exposed. This occurs in three principal settings: underwater diving, hyperbaric oxygen therapy, and the provision of supplemental oxygen, particularly to premature infants. In each case, the risk factors are markedly different.
Central nervous system toxicity
Exposures, from minutes to a few hours, to partial pressures of oxygen above 1.6 bars (160 kPa)—about eight times the standard atmospheric partial pressure—are usually associated with central nervous system oxygen toxicity and are most likely to occur among patients undergoing hyperbaric oxygen therapy and divers. Since sea level atmospheric pressure is about 1 bar (100 kPa), central nervous system toxicity can only occur under hyperbaric conditions, where ambient pressure is above normal. Divers breathing air at depths greater than 60 m (200 ft) face an increasing risk of an oxygen toxicity "hit" (seizure). Divers breathing a gas mixture enriched with oxygen, such as nitrox, can similarly suffer a seizure at shallower depths, should they descend below the maximum operating depth allowed for the mixture.
The lungs, as well as the remainder of the respiratory tract, are exposed to the highest concentration of oxygen in the human body and are therefore the first organs to show toxicity. Pulmonary toxicity occurs with exposure to partial pressures of oxygen greater than 0.5 bar (50 kPa), corresponding to an oxygen fraction of 50% at normal atmospheric pressure. Signs of pulmonary toxicity begins with evidence of tracheobronchitis, or inflammation of the upper airways, after an asymptomatic period between 4 and 22 hours at greater than 95% oxygen, with some studies suggesting symptoms usually begin after approximately 14 hours at this level of oxygen.
At partial pressures of oxygen of 2 to 3 bar (200 to 300 kPa)—100% oxygen at 2 to 3 times atmospheric pressure—these symptoms may begin as early as 3 hours after exposure to oxygen. Experiments on rats breathing oxygen at pressures between 1 and 3 bars (100 and 300 kPa) show that pulmonary manifestations of oxygen toxicity are not the same for normobaric conditions as they are for hyperbaric conditions. Evidence of decline in lung function as measured by pulmonary function testing can occur as quickly as 24 hours of continuous exposure to 100% oxygen, with evidence of diffuse alveolar damage and the onset of acute respiratory distress syndrome usually occurring after 48 hours on 100% oxygen. Breathing 100% oxygen also eventually leads to collapse of the alveoli (atelectasis), while—at the same partial pressure of oxygen—the presence of significant partial pressures of inert gases, typically nitrogen, will prevent this effect.
Preterm newborns are known to be at higher risk for bronchopulmonary dysplasia with extended exposure to high concentrations of oxygen. Other groups at higher risk for oxygen toxicity are patients on mechanical ventilation with exposure to levels of oxygen greater than 50%, and patients exposed to chemicals that increase risk for oxygen toxicity such the chemotherapeutic agent bleomycin. Therefore, current guidelines for patients on mechanical ventilation in intensive care recommends keeping oxygen concentration less than 60%. Likewise, divers who undergo treatment of decompression sickness are at increased risk of oxygen toxicity as treatment entails exposure to long periods of oxygen breathing under hyperbaric conditions, in addition to any oxygen exposure during the dive.
Prolonged exposure to high inspired fractions of oxygen causes damage to the retina. Damage to the developing eye of infants exposed to high oxygen fraction at normal pressure has a different mechanism and effect from the eye damage experienced by adult divers under hyperbaric conditions. Hyperoxia may be a contributing factor for the disorder called retrolental fibroplasia or retinopathy of prematurity (ROP) in infants. In preterm infants, the retina is often not fully vascularised. Retinopathy of prematurity occurs when the development of the retinal vasculature is arrested and then proceeds abnormally. Associated with the growth of these new vessels is fibrous tissue (scar tissue) that may contract to cause retinal detachment. Supplemental oxygen exposure, while a risk factor, is not the main risk factor for development of this disease. Restricting supplemental oxygen use does not necessarily reduce the rate of retinopathy of prematurity, and may raise the risk of hypoxia-related systemic complications.
Hyperoxic myopia has occurred in closed circuit oxygen rebreather divers with prolonged exposures. It also occurs frequently in those undergoing repeated hyperbaric oxygen therapy. This is due to an increase in the refractive power of the lens, since axial length and keratometry readings do not reveal a corneal or length basis for a myopic shift. It is usually reversible with time.
The biochemical basis for the toxicity of oxygen is the partial reduction of oxygen by one or two electrons to form reactive oxygen species, which are natural by-products of the normal metabolism of oxygen and have important roles in cell signalling. One species produced by the body, the superoxide anion (O
2–), is possibly involved in iron acquisition. Higher than normal concentrations of oxygen lead to increased levels of reactive oxygen species. Oxygen is necessary for cell metabolism, and the blood supplies it to all parts of the body. When oxygen is breathed at high partial pressures, a hyperoxic condition will rapidly spread, with the most vascularised tissues being most vulnerable. During times of environmental stress, levels of reactive oxygen species can increase dramatically, which can damage cell structures and produce oxidative stress.
While all the reaction mechanisms of these species within the body are not yet fully understood, one of the most reactive products of oxidative stress is the hydroxyl radical (·OH), which can initiate a damaging chain reaction of lipid peroxidation in the unsaturated lipids within cell membranes. High concentrations of oxygen also increase the formation of other free radicals, such as nitric oxide, peroxynitrite, and trioxidane, which harm DNA and other biomolecules. Although the body has many antioxidant systems such as glutathione that guard against oxidative stress, these systems are eventually overwhelmed at very high concentrations of free oxygen, and the rate of cell damage exceeds the capacity of the systems that prevent or repair it. Cell damage and cell death then result.
Diagnosis of central nervous system oxygen toxicity in divers prior to seizure is difficult as the symptoms of visual disturbance, ear problems, dizziness, confusion and nausea can be due to many factors common to the underwater environment such as narcosis, congestion and coldness. However, these symptoms may be helpful in diagnosing the first stages of oxygen toxicity in patients undergoing hyperbaric oxygen therapy. In either case, unless there is a prior history of epilepsy or tests indicate hypoglycaemia, a seizure occurring in the setting of breathing oxygen at partial pressures greater than 1.4 bar (140 kPa) suggests a diagnosis of oxygen toxicity.
Diagnosis of bronchopulmonary dysplasia in newborn infants with breathing difficulties is difficult in the first few weeks. However, if the infant's breathing does not improve during this time, blood tests and x-rays may be used to confirm bronchopulmonary dysplasia. In addition, an echocardiogram can help to eliminate other possible causes such as congenital heart defects or pulmonary arterial hypertension.
The diagnosis of retinopathy of prematurity in infants is typically suggested by the clinical setting. Prematurity, low birth weight and a history of oxygen exposure are the principal indicators, while no hereditary factors have been shown to yield a pattern.
The prevention of oxygen toxicity depends entirely on the setting. Both underwater and in space, proper precautions can eliminate the most pernicious effects. Premature infants commonly require supplemental oxygen to treat complications of preterm birth. In this case prevention of bronchopulmonary dysplasia and retinopathy of prematurity must be carried out without compromising a supply of oxygen adequate to preserve the infant's life.
Oxygen toxicity is a catastrophic hazard in diving, because a seizure results in near certain death by drowning. The seizure may occur suddenly and with no warning symptoms. The effects are sudden convulsions and unconsciousness, during which victims can lose their regulator and drown. One of the advantages of a full-face diving mask is prevention of regulator loss in the event of a seizure. As there is an increased risk of central nervous system oxygen toxicity on deep dives, long dives and dives where oxygen-rich breathing gases are used, divers are taught to calculate a maximum operating depth for oxygen-rich breathing gases, and cylinders containing such mixtures must be clearly marked with that depth.
In some diver training courses for these types of diving, divers are taught to plan and monitor what is called the oxygen clock of their dives. This is a notional alarm clock, which ticks more quickly at increased ppO
2 and is set to activate at the maximum single exposure limit recommended in the National Oceanic and Atmospheric Administration Diving Manual. For the following partial pressures of oxygen the limit is: 45 minutes at 1.6 bar (160 kPa), 120 minutes at 1.5 bar (150 kPa), 150 minutes at 1.4 bar (140 kPa), 180 minutes at 1.3 bar (130 kPa) and 210 minutes at 1.2 bar (120 kPa), but is impossible to predict with any reliability whether or when toxicity symptoms will occur. Many nitrox-capable dive computers calculate an oxygen loading and can track it across multiple dives. The aim is to avoid activating the alarm by reducing the ppO
2 of the breathing gas or the length of time breathing gas of higher ppO
2. As the ppO
2 depends on the fraction of oxygen in the breathing gas and the depth of the dive, the diver obtains more time on the oxygen clock by diving at a shallower depth, by breathing a less oxygen-rich gas, or by shortening the duration of exposure to oxygen-rich gases.
Diving below 56 m (184 ft) on air would expose a diver to increasing danger of oxygen toxicity as the partial pressure of oxygen exceeds 1.4 bar (140 kPa), so a gas mixture must be used which contains less than 21% oxygen (a hypoxic mixture). Increasing the proportion of nitrogen is not viable, since it would produce a strongly narcotic mixture. However, helium is not narcotic, and a usable mixture may be blended either by completely replacing nitrogen with helium (the resulting mix is called heliox), or by replacing part of the nitrogen with helium, producing a trimix.
Pulmonary oxygen toxicity is an entirely avoidable event while diving. The limited duration and naturally intermittent nature of most diving makes this a relatively rare (and even then, reversible) complication for divers. Guidelines have been established that allow divers to calculate when they are at risk of pulmonary toxicity.
The presence of a fever or a history of seizure is a relative contraindication to hyperbaric oxygen treatment. The schedules used for treatment of decompression illness allow for periods of breathing air rather than 100% oxygen (oxygen breaks) to reduce the chance of seizure or lung damage. The U.S. Navy uses treatment tables based on periods alternating between 100% oxygen and air. For example, USN table 6 requires 75 minutes (three periods of 20 minutes oxygen/5 minutes air) at an ambient pressure of 2.8 standard atmospheres (280 kPa), equivalent to a depth of 18 metres (60 ft). This is followed by a slow reduction in pressure to 1.9 atm (190 kPa) over 30 minutes on oxygen. The patient then remains at that pressure for a further 150 minutes, consisting of two periods of 15 minutes air/60 minutes oxygen, before the pressure is reduced to atmospheric over 30 minutes on oxygen.
Vitamin E and selenium were proposed and later rejected as a potential method of protection against pulmonary oxygen toxicity. There is however some experimental evidence in rats that vitamin E and selenium aid in preventing in vivo lipid peroxidation and free radical damage, and therefore prevent retinal changes following repetitive hyperbaric oxygen exposures.
Bronchopulmonary dysplasia is reversible in the early stages by use of break periods on lower pressures of oxygen, but it may eventually result in irreversible lung injury if allowed to progress to severe damage. One or two days of exposure without oxygen breaks are needed to cause such damage.
Retinopathy of prematurity is largely preventable by screening. Current guidelines require that all babies of less than 32 weeks gestational age or having a birth weight less than 1.5 kg (3.3 lb) should be screened for retinopathy of prematurity at least every two weeks. The National Cooperative Study in 1954 showed a causal link between supplemental oxygen and retinopathy of prematurity, but subsequent curtailment of supplemental oxygen caused an increase in infant mortality. To balance the risks of hypoxia and retinopathy of prematurity, modern protocols now require monitoring of blood oxygen levels in premature infants receiving oxygen.
In low-pressure environments oxygen toxicity may be avoided since the toxicity is caused by high partial pressure of oxygen, not merely by high oxygen fraction. This is illustrated by modern pure oxygen use in spacesuits, which must operate at low pressure (also historically, very high percentage oxygen and lower than normal atmospheric pressure was used in early spacecraft, for example, the Gemini and Apollo spacecraft). In such applications as extra-vehicular activity, high-fraction oxygen is non-toxic, even at breathing mixture fractions approaching 100%, because the oxygen partial pressure is not allowed to chronically exceed 0.3 bar (4.4 psi).
During hyperbaric oxygen therapy, the patient will usually breathe 100% oxygen from a mask while inside a hyperbaric chamber pressurised with air to about 2.8 bar (280 kPa). Seizures during the therapy are managed by removing the mask from the patient, thereby dropping the partial pressure of oxygen inspired below 0.6 bar (60 kPa).
A seizure underwater requires that the diver be brought to the surface as soon as practicable. Although for many years the recommendation has been not to raise the diver during the seizure itself, owing to the danger of arterial gas embolism (AGE), there is some evidence that the glottis does not fully obstruct the airway. This has led to the current recommendation by the Diving Committee of the Undersea and Hyperbaric Medical Society that a diver should be raised during the seizure's clonic (convulsive) phase if the regulator is not in the diver's mouth – as the danger of drowning is then greater than that of AGE – but the ascent should be delayed until the end of the clonic phase otherwise. Rescuers ensure that their own safety is not compromised during the convulsive phase. They then ensure that where the victim's air supply is established it is maintained, and carry out a controlled buoyant lift. Lifting an unconscious body is taught by most diver training agencies. Upon reaching the surface, emergency services are always contacted as there is a possibility of further complications requiring medical attention. The U.S. Navy has procedures for completing the decompression stops where a recompression chamber is not immediately available.
The occurrence of symptoms of bronchopulmonary dysplasia or acute respiratory distress syndrome is treated by lowering the fraction of oxygen administered, along with a reduction in the periods of exposure and an increase in the break periods where normal air is supplied. Where supplemental oxygen is required for treatment of another disease (particularly in infants), a ventilator may be needed to ensure that the lung tissue remains inflated. Reductions in pressure and exposure will be made progressively, and medications such as bronchodilators and pulmonary surfactants may be used.
Retinopathy of prematurity may regress spontaneously, but should the disease progress beyond a threshold (defined as five contiguous or eight cumulative hours of stage 3 retinopathy of prematurity), both cryosurgery and laser surgery have been shown to reduce the risk of blindness as an outcome. Where the disease has progressed further, techniques such as scleral buckling and vitrectomy surgery may assist in re-attaching the retina.
Although the convulsions caused by central nervous system oxygen toxicity may lead to incidental injury to the victim, it remained uncertain for many years whether damage to the nervous system following the seizure could occur and several studies searched for evidence of such damage. An overview of these studies by Bitterman in 2004 concluded that following removal of breathing gas containing high fractions of oxygen, no long-term neurological damage from the seizure remains.
The majority of infants who have survived following an incidence of bronchopulmonary dysplasia will eventually recover near-normal lung function, since lungs continue to grow during the first 5–7 years and the damage caused by bronchopulmonary dysplasia is to some extent reversible (even in adults). However, they are likely be more susceptible to respiratory infections for the rest of their lives and the severity of later infections is often greater than that in their peers.
Retinopathy of prematurity (ROP) in infants frequently regresses without intervention and eyesight may be normal in later years. Where the disease has progressed to the stages requiring surgery, the outcomes are generally good for the treatment of stage 3 ROP, but are much worse for the later stages. Although surgery is usually successful in restoring the anatomy of the eye, damage to the nervous system by the progression of the disease leads to comparatively poorer results in restoring vision. The presence of other complicating diseases also reduces the likelihood of a favourable outcome.
The incidence of central nervous system toxicity among divers has decreased since the Second World War, as protocols have developed to limit exposure and partial pressure of oxygen inspired. In 1947, Donald recommended limiting the depth allowed for breathing pure oxygen to 7.6 m (25 ft), or a ppO
2 of 1.8 bar (180 kPa). This limit has been reduced, until today a limit of 1.4 bar (140 kPa) during a recreational dive and 1.6 bar (160 kPa) during shallow decompression stops is accepted. Oxygen toxicity has now become a rare occurrence other than when caused by equipment malfunction and human error. Historically, the U.S. Navy has refined its Navy Diving Manual Tables to reduce oxygen toxicity incidents. Between 1995 and 1999, reports showed 405 surface-supported dives using the helium–oxygen tables; of these, oxygen toxicity symptoms were observed on 6 dives (1.5%). As a result, the U.S. Navy in 2000 modified the schedules and conducted field tests of 150 dives, none of which produced symptoms of oxygen toxicity. Revised tables were published in 2001.
The variability in tolerance and other variable factors such as workload have resulted in the U.S. Navy abandoning screening for oxygen tolerance. Of the 6,250 oxygen-tolerance tests performed between 1976 and 1997, only 6 episodes of oxygen toxicity were observed (0.1%).
Central nervous system oxygen toxicity among patients undergoing hyperbaric oxygen therapy is rare, and is influenced by a number of a factors: individual sensitivity and treatment protocol; and probably therapy indication and equipment used. A study by Welslau in 1996 reported 16 incidents out of a population of 107,264 patients (0.015%), while Hampson and Atik in 2003 found a rate of 0.03%. Yildiz, Ay and Qyrdedi, in a summary of 36,500 patient treatments between 1996 and 2003, reported only 3 oxygen toxicity incidents, giving a rate of 0.008%. A later review of over 80,000 patient treatments revealed an even lower rate: 0.0024%. The reduction in incidence may be partly due to use of a mask (rather than a hood) to deliver oxygen.
Bronchopulmonary dysplasia is among the most common complications of prematurely born infants and its incidence has grown as the survival of extremely premature infants has increased. Nevertheless, the severity has decreased as better management of supplemental oxygen has resulted in the disease now being related mainly to factors other than hyperoxia.
In 1997 a summary of studies of neonatal intensive care units in industrialised countries showed that up to 60% of low birth weight babies developed retinopathy of prematurity, which rose to 72% in extremely low birth weight babies, defined as less than 1 kg (2.2 lb) at birth. However, severe outcomes are much less frequent: for very low birth weight babies—those less than 1.5 kg (3.3 lb) at birth—the incidence of blindness was found to be no more than 8%.
Central nervous system toxicity was first described by Paul Bert in 1878. He showed that oxygen was toxic to insects, arachnids, myriapods, molluscs, earthworms, fungi, germinating seeds, birds, and other animals. Central nervous system toxicity may be referred to as the "Paul Bert effect".
Pulmonary oxygen toxicity was first described by J. Lorrain Smith in 1899 when he noted central nervous system toxicity and discovered in experiments in mice and birds that 0.43 bar (43 kPa) had no effect but 0.75 bar (75 kPa) of oxygen was a pulmonary irritant. Pulmonary toxicity may be referred to as the "Lorrain Smith effect". The first recorded human exposure was undertaken in 1910 by Bornstein when two men breathed oxygen at 2.8 bar (280 kPa) for 30 minutes while he went on to 48 minutes with no symptoms. In 1912, Bornstein developed cramps in his hands and legs while breathing oxygen at 2.8 bar (280 kPa) for 51 minutes. Smith then went on to show that intermittent exposure to a breathing gas with less oxygen permitted the lungs to recover and delayed the onset of pulmonary toxicity.
Albert R. Behnke et al. in 1935 were the first to observe visual field contraction (tunnel vision) on dives between 1.0 bar (100 kPa) and 4.1 bar (410 kPa). During World War II, Donald and Yarbrough et al. performed over 2,000 experiments on oxygen toxicity to support the initial use of closed circuit oxygen rebreathers. Naval divers in the early years of oxygen rebreather diving developed a mythology about a monster called "Oxygen Pete", who lurked in the bottom of the Admiralty Experimental Diving Unit "wet pot" (a water-filled hyperbaric chamber) to catch unwary divers. They called having an oxygen toxicity attack "getting a Pete".
In the decade following World War II, Lambertsen et al. made further discoveries on the effects of breathing oxygen under pressure as well as methods of prevention. Their work on intermittent exposures for extension of oxygen tolerance and on a model for prediction of pulmonary oxygen toxicity based on pulmonary function are key documents in the development of standard operating procedures when breathing elevated pressures of oxygen. Lambertsen's work showing the effect of carbon dioxide in decreasing time to onset of central nervous system symptoms has influenced work from current exposure guidelines to future breathing apparatus design.
Retinopathy of prematurity was not observed prior to World War II, but with the availability of supplemental oxygen in the decade following, it rapidly became one of the principal causes of infant blindness in developed countries. By 1960 the use of oxygen had become identified as a risk factor and its administration restricted. The resulting fall in retinopathy of prematurity was accompanied by a rise in infant mortality and hypoxia-related complications. Since then, more sophisticated monitoring and diagnosis have established protocols for oxygen use which aim to balance between hypoxic conditions and problems of retinopathy of prematurity.
Bronchopulmonary dysplasia was first described by Northway in 1967, who outlined the conditions that would lead to the diagnosis. This was later expanded by Bancalari and in 1988 by Shennan, who suggested the need for supplemental oxygen at 36 weeks could predict long-term outcomes. Nevertheless, Palta et al. in 1998 concluded that radiographic evidence was the most accurate predictor of long-term effects.
Bitterman et al. in 1986 and 1995 showed that darkness and caffeine would delay the onset of changes to brain electrical activity in rats. In the years since, research on central nervous system toxicity has centred on methods of prevention and safe extension of tolerance. Sensitivity to central nervous system oxygen toxicity has been shown to be affected by factors such as circadian rhythm, drugs, age, and gender. In 1988, Hamilton et al. wrote procedures for the National Oceanic and Atmospheric Administration to establish oxygen exposure limits for habitat operations. Even today, models for the prediction of pulmonary oxygen toxicity do not explain all the results of exposure to high partial pressures of oxygen.
Society and culture
Recreational scuba divers commonly breathe nitrox containing up to 40% oxygen, while technical divers use pure oxygen or nitrox containing up to 80% oxygen. Divers who breathe oxygen fractions greater than of air (21%) need to be trained in the dangers of oxygen toxicity and how to prevent them. In order to buy nitrox, a diver has to show evidence of such qualification.
Since the late 1990s the recreational use of oxygen has been promoted by oxygen bars, where customers breathe oxygen through a nasal cannula. Claims have been made that this reduces stress, increases energy, and lessens the effects of hangovers and headaches, despite the lack of any scientific evidence to support them. There are also devices on sale that offer "oxygen massage" and "oxygen detoxification" with claims of removing body toxins and reducing body fat. The American Lung Association has stated "there is no evidence that oxygen at the low flow levels used in bars can be dangerous to a normal person's health", but the U.S. Center for Drug Evaluation and Research cautions that people with heart or lung disease need their supplementary oxygen carefully regulated and should not use oxygen bars.
Victorian society had a fascination for the rapidly expanding field of science. In "Dr. Ox's Experiment", a short story written by Jules Verne in 1872, the eponymous doctor uses electrolysis of water to separate oxygen and hydrogen. He then pumps the pure oxygen throughout the town of Quiquendone, causing the normally tranquil inhabitants and their animals to become aggressive and plants to grow rapidly. An explosion of the hydrogen and oxygen in Dr Ox's factory brings his experiment to an end. Verne summarised his story by explaining that the effects of oxygen described in the tale were his own invention. There is also a brief episode of oxygen intoxication in his "From the Earth to the Moon".
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- Clark, John M.; Lambertsen, Christian J. (1970). "Pulmonary oxygen tolerance in man and derivation of pulmonary oxygen tolerance curves". IFEM Report No. 1-70 (Philadelphia, PA: Environmental Biomedical Stress Data Center, Institute for Environmental Medicine, University of Pennsylvania Medical Center). Retrieved 29 April 2008.
- Donald, Kenneth W. (1947). "Oxygen Poisoning in Man: Part I". British Medical Journal 1 (4506): 667–672. doi:10.1136/bmj.1.4506.667. PMC 2053251. PMID 20248086.
- Donald, Kenneth W. (1947). "Oxygen Poisoning in Man: Part II". British Medical Journal 1 (4507): 712–717. doi:10.1136/bmj.1.4507.712. PMC 2053400. PMID 20248096.
- Revised version of Donald's articles also available as:
- Donald, Kenneth W. (1992). Oxygen and the diver. UK: Harley Swan, 237 pages. ISBN 1-85421-176-5. OCLC 26894235.
- Hamilton, Robert W.; Thalmann, Edward D. (2003). "Decompression practice". In Brubakk, Alf O.; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders. pp. 475–479. ISBN 978-0-7020-2571-6. OCLC 51607923.
- Lang, Michael A., ed. (2001). DAN nitrox workshop proceedings. Durham, NC: Divers Alert Network, 197 pages. Retrieved 20 September 2008.
- Regillo, Carl D.; Brown, Gary C.; Flynn, Harry W. (1998). Vitreoretinal Disease: The Essentials. New York: Thieme, 693 pages. ISBN 978-0-86577-761-3. OCLC 39170393.
- Lamb, John S. (1999). The Practice of Oxygen Measurement for Divers. Flagstaff: Best Publishing, 120 pages. ISBN 0-941332-68-3. OCLC 44018369.
- Lippmann, John; Bugg, Stan (1993). The Diving Emergency Handbook. Teddington, UK: Underwater World Publications. ISBN 0-946020-18-3. OCLC 52056845.
- Lippmann, John; Mitchell, Simon (2005). "Oxygen". Deeper into Diving (2nd ed.). Victoria, Australia: J.L. Publications. pp. 121–4. ISBN 0-9752290-1-X. OCLC 66524750.
The following external site is a compendium of resources:
- Rubicon Research Repository. – Online collection of the oxygen toxicity research
The following external sites contain resources specific to particular topics:
- 2008 Divers Alert Network Technical Diving Conference. – Video of "Oxygen Toxicity" lecture by Dr. Richard Vann (free download, mp4, 86MB).
- Physiology at MCG 4/4ch7/s4ch7_7. – Wide and detailed discussion of the effects of breathing oxygen on the respiratory system.
- Rajiah, Prabhakar (11 March 2009). "Bronchopulmonary Dysplasia". eMedicine. Retrieved 29 June 2009. – Concise clinical overview with extensive references. |
Includes an equal part of paper and electronically produced documents
Which of the following is not a description of a hybrid health record?
Version control is unnecessary.
Which of the following is not a true statement about a hybrid health record system?
Tasks that need to be performed in a specific sequence
Incorporating a workflow function in an electronic information system would help support:
Use mirrored processing on redundant servers
Which of the following would be the best course of action to take to ensure continuous availability of electronic data?
Electronic document management system
Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible?
Clinical data repository
Which of the following technologies would be best for a hospital to use to manage data from its laboratory, pharmacy, and radiology information systems?
Which of the following encourages patients to take an active role in collecting and storing their health information?
Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?
Ensures that appropriate data are collected
Why does an ideal EHR system include point-of-care template charting?
Electronic document management system
Which of the following is a transition strategy to achieve an EHR?
Pharmacy information system
To ensure that a computerized provider order entry (CPOE) system supports patient safety, what other system must also be in place?
Before contracting for an EHR product
As part of an EHR system selection, due diligence should be done:
Which form of wireless technology uses infrared light waves to beam data between devices in close proximity to one another?
A step-by-step approach to installing, testing, training, and gaining adoption for an EHR is referred to as:
Electronic point-of-care charting
Electronic systems used by nurses and physicians to document assessments and findings are called:
A SNF wanting to collect MDS assessments in a database and transmit them in a standard CMS format would use which of the following data entry software?
Data represent basic facts, while information represents meaning.
What is the difference between data and information?
Structure and content
Information standards that provide clear descriptors of data elements to be included in computer-based patient record systems are called __________ standards.
Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called:
Laboratory data are successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards?
Harmonization of standards from multiple sources
Since many private and public standards groups promulgate health informatics standards, the Office of the National Coordinator of Health Information Technology has been given responsibility for:
As a health information professional, you've become involved in developing an HIE in your region. The agency that would provide the best resources for HIE development is:
Which of the following vocabularies is likely to be used to describe drugs in clinically relevant form?
When some computers are used primarily to enter data and others to process data, the architecture is called:
Set of technologies, standards, applications, systems, values, and laws
Which of the following best describes the national health information infrastructure proposed by the National Committee on Vital and Health Statistics?
In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards?
Print out all documents and maintain these as a general practice
In attempting to control the patient safety issues associated with hybrid medical records, which of the following would be the best practice for a healthcare facility to do?
Which of the following describes the step during implementation when data from an old system are able to be incorporated into the new system?
Clinical professionals who provide direct patient care
Who are the primary users of the health record for delivery of healthcare services?
Natural language processing
Which of the following types of electronic data entry applies sophisticated mathematical and probabilistic formulas to narrative text and converts them to structured data?
Use radio buttons to select multiple items from a set of options.
Which of the following is not true of good electronic forms design?
Clinical forms committee
What committee usually oversees the development and approval of new forms for the health record?
Identity matching algorithm
The key for linking data about an individual who is seen in a variety of care settings is:
Patient registration department
The first point of data collection and the area where the health record number is most commonly assigned in an acute care hospital is the:
Serial numbering system
In which of the following systems does an individual receive a unique numerical identifier for each encounter with a healthcare facility?
Incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies and procedures are called:
EHR project manager
Which of the following individuals is responsible for ensuring that the steps in an EHR implementation are performed and coordinated among the various organization teams, committees, and vendor staff?
Which type of health record is designed to measure clinical outcomes, collect data at the point of care, and provide medical alerts?
Which of the following computer architectures uses a single large computer to process data received from terminals into which data are entered?
A transition technology used by many hospitals to increase access to medical record content is:
When a hospital develops its EHR system by selecting one vendor to provide financial and administrative applications and another vendor to supply the clinical applications, this is commonly referred to as a __________ strategy.
Best of breed
When a hospital develops its electronic health record system by selecting multiple vendors to supply all of its applications including financial, administrative, and clinical applications, this is commonly referred to as a strategy.
Social Security number
Which of the following should not be used as a patient identifier in an electronic environment?
Added to the health record after it has been processed by the HIM department
"Loose" reports are health record forms that are:
In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the __________ file.
Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system? 36-45-99 / 37-45-99 / 38-45-99
The MPI is necessary to physically locate health records within the paper-based storage system for all types of filing systems, except:
25 hours per day
The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 600 clinic visits per day. The standard for filing records is 60 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required daily to retrieve and file records for each clinic day?
Unit numbering system
In which of the following systems are all encounters or patient visits filed or linked together?
Uneven expansion of file shelves or cabinets
Which of the following is a disadvantage of alphabetic filing?
File the record alphabetically by the last name, followed by alphabetical order of the first name, and then alphabetical order of the middle initial.
Which of the following statements describes alphabetical filing?
Which of the following tools is usually used to track paper-based health records that have been removed from their permanent storage locations?
Which of the following features of the filing folder helps best to locate misfiles within the paper-based filing system?
Transaction processing system
What type of information system would be used for processing patient admissions, employee time cards, and purchase orders?
A healthcare enterprise wants to analyze data from multiple computer systems across the organization to determine trends in patient care services. Which of the following would best consolidate data for this purpose?
A system that manages data for an entire healthcare business is referred to as a(n):
Transmitters, receivers, media, and data
What basic components make up every electronic network communications system?
The first computer systems used in healthcare were used primarily to perform payroll and __________ functions.
Exchange data from any system within the organization
The concept of systems interoperability refers to the healthcare organization's ability to:
Bidding for the contract
The RFP generally includes a detailed description of the system's requirements and provides guidelines for vendors to follow in:
The most common approaches to converting from an old information system to a new one are the parallel approach, the phased approach, and the __________ approach.
Clinical information system
Which of the following systems is designed primarily to support patient care by providing healthcare professionals access to timely, complete, and relevant information for patient care purposes?
Laboratory information system
Which of the following information systems is used for collecting, verifying, and reporting test results?
Clinical decision support system
Which of the following information systems is used to assist healthcare providers in the actual diagnosis and treatment of patients?
Financial information system
Which of the following information systems is considered an administrative information system?
In which phase of the systems development life cycle is the primary focus on examining the current system and problems in order to identify opportunities for improvement or enhancement of the system?
In which phase of the systems development life cycle are trial runs of the new system conducted, backup and disaster recover procedures developed, and training of end users conducted?
Business and strategic issues
What is the main focus of the system planning phase of the systems development life cycle?
A computer station that engages patients in healthcare organization's services
Which of the following best describes the function of kiosks?
A medication being ordered is contraindicated due to a patient allergy. The physician is notified. This is an example of a(n):
Historical data used for strategic decision support
Which of the following best describes a data warehouse?
Which of the following systems supports the creation, organization, and dissemination of business expertise throughout the organization?
Management information system
Which of the following systems would the HIM department director use to receive daily reports on the number of new admissions to, and discharges from, the hospital?
Which of the following is a snapshot in time and consolidates data from multiple sources to enhance decision making?
Which of the following uses artificial intelligence techniques to capture the knowledge of human experts and to translate and store it in a knowledge base?
Which of the following stores data in predefined tables consisting of rows and columns?
Which of the following is a technique for graphically depicting the structure of a computer database?
Which of the following is a fifth-generation programming language that uses human
language to allow users to speak to computers in a more conversational way?
Which of the following connects computers together in a way that allows for the sharing of information and resources?
Which of the following is a network that connects computers in a relatively small area, such as a room or a building?
Allow healthcare providers to readily access information about a patient's healthcare at any point in time
The primary purpose of the Continuity of Care Record (CCR) is to:
In a network environment, a database shared among several end-user workstations would be stored on a:
Which of the following is a type of computer network specifically designed to allow direct communication between the networks of separate companies?
Which of the following enables sharing resources such as printers or disk space across a computer network?
Online medical supply purchasing
Which of the following best describes B2B e-commerce in a healthcare environment?
Application service provider
Companies that deliver, manage, and remotely host systems, such as an EMR or patient registration software via a network through an outsourcing contract are known as a(n):
Which of the following protocols is used to transfer and display information in the form of Web pages on browsers?
Which of the following is a family of standards that aid the exchange of data among hospital systems and physician practices?
Which of the following translate digital data into analog data so that data can be transmitted over telephone lines and received by a remote computer?
The data type should be changed to Character
The following descriptors about the data element PATIENT_LAST_NAME are included in a data dictionary: definition: legal surname of the patient; data type: numeric; field length: 50; required field: yes; default value: none; input mask: none. Which of the following is true about the definition of this data element?
The coding supervisor wants a daily report of health records that need to be coded. Which of the following systems would be best in meeting the supervisor's needs?
The type of testing of a new electronic information system that ensures that the system can adequately handle a large number of users or transactions is:
A clinic wants to purchase a new healthcare information system. Who is responsible for preparing the RFP to gather information about the functionality of the new system?
'Which of the following are used to associate relationships between entities (tables) in a relational database?
Validation rules for values in a field
In an EMR database, which of the following would be considered an integrity constraint?
Which of the following is a process that identifies patterns and relationships by searching through large amounts of data?
Which of the following types of network topologies has the least chance of failure for bringing down the entire computer network?
Which of the following would be used as an Internet standard for e-mail transmission across Internet protocol (IP) networks?
For at least 5 years
In the absence of state or federal law, AHIMA's retention standards recommend that diagnostic images such as x-rays be maintained:
For at least 10 years after the most recent encounter
In the absence of state or federal law, AHIMA's retention standards recommend that the health records of adults be maintained:
Security awareness program
Which of the following is not an automatic application control that helps preserve data confidentiality and integrity in an electronic system?
Access to information
Within the context of data security, protecting data privacy means defending or safeguarding:
The protection measures and tools for safeguarding information and information systems is a definition of:
The __________ provide(s) the objective and scope for the HIPAA Security rule as a whole.
The covered entity must conduct a risk assessment to determine if the specification is appropriate to its environment.
For HIPAA security implementation specifications that are addressable, which of the following statements is true?
Computer shutdowns caused by intentional or unintentional events
The primary reason that healthcare organizations develop business continuity plans is to minimize the effects of:
Physical access controls
Which of the following are security safeguards that protect equipment, media, and facilities?
Establish a contingency plan
Which of the following must covered entities do in order to comply with HIPAA security provisions?
Data must be encrypted when deemed appropriate from the results of a risk assessment.
Which of the following statements is true regarding HIPAA standards for encryption?
Which of the following are security controls built into a computer software program?
Which of the following are designed to prevent damage caused by computer hackers using the Internet?
Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security?
The mechanisms for safeguarding information and information systems
Which of the following best describes information security?
In the context of data security, which of the following terms means that data should be complete, accurate, and consistent?
Business continuity plan
Which of the following is an organization's planned response to protect its information in the case of a natural disaster?
Once a year
To ensure relevancy, an organization's security policies and procedures be reviewed at least:
Which of the following is a software program that tracks every access to data in the computer system?
Fully digital EHR system
A clinic is evaluating options for an EHR system. The selection committee wants a system that provides simultaneous access to the record by different providers and administrative services employees. It also wants the system to perform various types of data analyses on discrete data. The system must electronically store forms and information so paper storage is completely eliminated. Which of the following would be the best fit for the requirements the committee wants?
Implement a document scanning system for the paper records and interface data created in the current EHR with the document scanning system
A hospital is concerned about the difficulty in retrieving health records for patient care and legal purposes. Some of its data are stored electronically while the remainder are stored on paper. The hospital knows it will be several years before it will be able to implement an entire EHR system and go paperless. Given this information, which of the following would be the best solution for the hospital to ensure that all of the data for a patient are retrieved when needed?
A system whereby documents are scanned by a document imaging system and then integrated and indexed into the existing EHR
Which of the following hybrid models comes closest to a total EHR system?
Shading of bars or lines that contain text
Which of the following should be avoided when designing forms for an EDMS?
24 lb. weight paper for double-sided forms
Which of the following is recommended for design of forms for an EDMS?
Implement session terminations
A hospital is planning on allowing coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that workstations are not left unattended at home offices?
User name, password, and security question
A home health agency plans to implement a computer system that permits nursing documentation on a laptop computer taken to the patient's home. The agency is in the process of identifying strategies to minimize the risks associated with the practice. With regard to access to data on the laptop, which of the following would be best for securing data?
Ask the security officer for audit trail data to confirm or disprove the suspicion
The HIM supervisor suspects that a departmental employee is using the Internet for personal business but has no specific data to support this suspicion. In this case, what should the supervisor do?
Scan all documents at the time of patient discharge
A HIM department is researching various options for scanning the hospital's health records. The department director would like to achieve efficiencies through scanning such as performing coding and cancer registry functions remotely. Given these considerations, which of the following would be the best scanning process?
Document name, media type, source system, electronic storage start date, stop printing start date
Which of the following data sets would be most useful in developing a grid for identification of components of the legal health record in a hybrid record environment?
What component of the departmental budget would include the expense of purchasing new reference books for clinical coding staff?
Which of the following is capable of providing video, audio, computer, and imaging system connectivity for virtual teamwork?
Determination of the quickest solution
Which of the following is not a step in quality improvement decision-making?
Be dedicated to achieving the organizational vision
During times of change, it is important for the supervisor to:
Environmental assessments are performed as part of which of the following processes?
Which of the following is a description of what the organization would like to be in the future?
A summary of the job position, a list of duties, and the qualifications required to perform the job are all elements of a(n):
The organizational structure affects the way its employees interact with each other
One unchanging principle of organizational behavior is that:
On the job training
Which of the following provides direct, realistic training in the specific tasks required by the job position?
Which of the following describes the type of behavior the organization wants to encourage among its employees?
A coding supervisor who makes up the weekly work schedule would engage in what type of planning?
360 degree evaluation
Which of the following would the supervisor and peers contribute to an individual's performance evaluation? |
Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
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Dr. Jill F Diamond has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Jill F Diamond has the following 5 expertise
- Pediatric Diabetes
Dr. Jill F Diamond has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Jill F Diamond is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
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I would never recommend anyone to Dr. Diamond or to this practice. In addition to seeing Dr. Diamond, he saw several other doctors as well as the nurse practioner, all of whom mid-diagnosed him with something that is very common. It wasn't until we changed pediatricians that we are now seeing positive results. It's sad that so many health care professionals couldn't figure it out. I think the practice is too big and there is no continuity. Awful experience and I want people to know so you don't have to go through months of your child suffering for something that could've been treated much sooner. Because I had to give a rating, I chose one star, but if I had my choice it would've been none.
Dr. Diamond is affiliated (can practice and admit patients) with the following hospital(s).
20 Years Experience
Tufts University School Of Medicine
Graduated in 1998
Baystate Medical Center
Dr. Jill F Diamond accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS MA Blue Care Elect PPO
- BCBS MA HMO Blue with Managed Care Behavioral Health
- BCBS MA Preferred Blue PPO
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- Harvard Pilgrim ChoiceNet HMO
- Harvard Pilgrim HMO
- Harvard Pilgrim PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Multiplan PPO
- PHCS PPO
Tufts Health Plan
- Tufts PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsPediatric Health Care Associates PC, 10 Centennial Dr Ste L, Peabody, MA
Dr. Jill F Diamond is similar to the following 3 Doctors near Peabody, MA. |
Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- Pregnancy Facts about pregnancy, including symptoms you can expect to have.
- Ragweed Allergy Ragweed allergy facts: symptoms, how to avoid it, trigger foods.
- Seasonal Allergies Facts about seasonal allergies, the different types and the symptoms.
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Book Online Now
Dr. Roosje S De Grauw has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Roosje S De Grauw has the following 5 expertise
- Pediatric Diabetes
Dr. Roosje S De Grauw has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Roosje S De Grauw is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
There are no reviews for Dr. Roosje S De Grauw yet. Be the first to review this doctor!
Bridges to Excellence: Physician Office Systems Recognition Program
This program is designed to recognize practices that use information systems to enhance the quality of patient care. To obtain Recognition, practices must demonstrate that they have implemented systematic office
8 Years Experience
University Of Cincinnati College Of Medicine
Graduated in 2010
Indiana University Hospital
Dr. Roosje S De Grauw accepts the following insurance providers.
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS MA Blue Care Elect PPO
- BCBS MA Preferred Blue PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- Empire Blue Priority EPO
- Empire HMO
- Empire PPO
- Empire Prism EPO Blue Priority
MVP Health Plan
- MVP Preferred PPO
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsAdvanced Specialty Care, 500 Commack Rd, Commack, NY
Dr. Roosje S De Grauw is similar to the following 3 Doctors near Commack, NY. |
Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Arrhythmia Facts about arrythmia, inclding the types, symptoms and causes.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Atrial Fibrillation Facts about atrial fibrillation, including symptoms and risk factors.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Coronary Artery Angioplasty with Stent Coronary artery angioplasty with stent facts, including who needs it.
- Coronary Heart Disease Get the facts about coronary heart disease.
- Deep Vein Thrombosis Facts about deep vein thrombosis (DVT), including symptoms & causes.
- Erectile Dysfunction Facts about erectile dysfunction (ED), including causes.
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Book Online Now
Dr. Bradley W Robinson has the following 2 specialties
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
- Pediatric Cardiology
Pediatric cardiologists are pediatricians with additional, specialized, training in the heart health of your children. When infants are born with congenital heart disease or abnormal hearts, pediatric cardiologists get involved as soon as possible — sometimes before the child is even born.
Through specific testing, they can diagnose the problem and care for the child throughout their treatment, which could range from medication to surgery and transplants. Other heart conditions they treat include arrhythmias, heart murmurs, holes in the heart and viral infections that affect blood flow.
Dr. Bradley W Robinson has the following 3 expertise
- Congenital Heart Disease (Patent Ductus Arteriosus)
- Congenital Heart Defects
Dr. Bradley W Robinson has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Bradley W Robinson is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
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Castle Connolly Regional Top Doctors
Castle Connolly is America's trusted source for the identification of Top Doctors. Their physician-led research team reviews and screens the credentials of tens of thousands of physicians who are nominated by their peers annually, via a nationwide online process, before selecting those physicians who are regionally or nationally among the very best in their medical specialties. Castle Connolly believes strongly that Top Doctors Make a Difference™.
32 Years Experience
University Of North Carolina At Chapel Hill School Of Medicine
Graduated in 1986
Jackson Health System
Dr. Bradley W Robinson accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Select
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry DE PPO
- Coventry HealthAmerica PPO
- Coventry Southern Health PPO
- First Health PPO
Geisinger Health Plan
- Geisinger Health Plan
- Highmark Community Blue PPO
- Horizon BCBS OMNIA - TIER1
- Horizon Direct Access
- Horizon HMO
- Horizon POS
- Horizon PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- IBC Keystone HMO POS
- IBC Personal Choice PPO
- Multiplan PPO
- QualCare HMO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsNemours Alfred I Dupont Hospital For Children, 1600 Rockland Rd, Wilmington, DE
Take a minute to learn about Dr. Bradley W Robinson, MD - Pediatric Cardiology in Wilmington, DE, in this video.
Dr. Bradley W Robinson is similar to the following 3 Doctors near Wilmington, DE. |
Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
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- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
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About Dr. Amaraseeli S Durayappah
Dr. Amaraseeli S Durayappah, MD is a Doctor primarily located in Houston, TX. She has 46 years of experience. Her specialties include Family Medicine. She speaks English.
Dr. Amaraseeli S Durayappah has the following 1 specialty
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. Amaraseeli S Durayappah has the following 7 expertise
- Family Planning
- Weight Loss
- Weight Loss (non-surgical)
Dr. Amaraseeli S Durayappah has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 3 of 10
Dont get me wrong but she was a verry good doctor at one point.we have been going to her office since my first born 15yrs ago but know she has slacked off alot..I have two younger children now a 4yr.old and 1yr.old & dosent do her job like she use to.shes not really intrested in what you have to say or what your diagnosed results are its more like a get in & get out visit..I think shes getting to old and always looks tired & not intrested in her job anymore.
My kids changed doctors several times in the beginning then I was introduced to Dr. Durayappah and they have been in her office since they were 18 months and 6 months old. My kids are now 9 and 7 and we will continue going there until she retires from practice. I was introduced to this Dr. by a family friend who had her when she was young and now takes her children to her office.
46 Years Experience
Medical College Of Georgia School Of Medicine
Graduated in 1972
Dr. Amaraseeli S Durayappah accepts the following insurance providers.
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS TX Blue Advantage HMO
- BCBS TX BlueChoice
- BCBS TX HMO Blue Texas
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana HMO
- Humana HMO Premier
- Humana National HMO
- Humana National POS
- Humana Preferred PPO
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsFamily Care Clinic, 8762 Long Point Rd Ste 106, Houston, TX
Dr. Amaraseeli S Durayappah is similar to the following 3 Doctors near Houston, TX. |
Get the facts about bipolar disorder, including the different types and symptoms of each.
- Bipolar Disorder Facts about bipolar disorder, including different types and symptoms.
- ADHD Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Adult ADHD Facts about attention deficit hyperactivity disorder (ADHD) in adults.
- Alzheimer's Disease Facts about Alzheimer’s Disease, including the symptoms and stages.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Chronic Pain Facts about chronic pain, including body parts most commonly affected.
- Clinical Depression Clinical depression facts; symptoms & other depressive disorders.
- Depression Facts about depression, including the symptoms of the condition.
- Diabetic Neuropathy Facts about diabetic neuropathy, including the symptoms and doctors.
- Epilepsy Facts about epilepsy, including different types, symptoms and causes.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Book Online Now
About Dr. Kellee R Clougherty
Dr. Kellee R Clougherty, MD is a Doctor primarily located in Laguna Niguel, CA, with another office in Del Mar, CA. She has 26 years of experience. Her specialties include Child and Adolescent Psychiatry, Psychiatry and Neurology. Dr. Clougherty has received 1 award. She speaks English.
Dr. Kellee R Clougherty has the following 3 specialties
- Child and Adolescent Psychiatry
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
A neurologist is a physician who diagnoses and treats disorders of the nervous system which is comprised of the brain, spinal cord and nerves. These doctors do not perform surgery, but refer patients to neurological surgeons when they determine that surgical intervention is necessary.
Some of the conditions that neurologists diagnose and treat are epilepsy, aneurysms, hydrocephalus, Parkinson's disease, multiple sclerosis, stroke, spinal disc herniation, and spinal disease.
In addition to using diagnostic tests like MRI, CT scans, EEG and EMG, neurologists also employ neurological testing to gauge muscle strength and movement, balance, reflexes, sensation, memory, speech, and other cognitive abilities.
Dr. Kellee R Clougherty has the following 13 expertise
- Personality Disorder
- Manic Depressive Disorder
- Mental Illness
- Clinical Depression
- Depressive Disorder
- Mood Disorders
- Sleep Disorders
- Bipolar Disorder
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
Dr. Kellee R Clougherty has 2 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Kellee R Clougherty is Board Certified in 2 specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 5 of 22
I brought my 8 year old daughter in for an ADHD evaluation, as the school counselor suggested my daughter may had adhd. I found Dr Clougherty to be very thorough in her evaluation. She spent a lot of time with us before the appointment over the phone, and then a lot of time both with me and with our daughter. We are considering medication, but she went over all our options, risks vs benefits and how it would benefit my daughter. I found her helpful and beneficial
I saw Dr Clougherty for depression and anxiety. I have had terrific results with the medication and Therapy. I find her courteous, conscientious, compassionate, and thoughtful. I had some slight stomach upset with the meds in the beginning, and she got me in the same day to discuss my care. I'm doing great thanks to Dr Clougherty.
Don't make the same painful mistake my family made. I thought all physicians got poor ratings posted about them...but the stern cautions voiced here could have saved us great anguish. We trusted Dr. Kellee Clougherty with the care of our teenager struggling with depression. Our 8 visit experience was so detrimental, I am compelled to share here the sternest of warnings! This psychiatrist was unprofessional, impatient, rude, superficial, disconnected and self-serving. Her real concern was only felt when we left. Even if Dr. Clougherty is the ONLY adolescent psychiatrist on your health plan, go out-of-network before wasting your time with this one!
I have been seeing Dr Clougherty for over a year now, and must say that she is at the top of her game.Not only did she get me off the medication that was causing me numerous problems, but she has been the one that has caused me to be much more in control of my life. Her practice is busy, and she has rules about cancellations. She has to! if you follow the rules that she outlines for her office, all will be good!
On-Time Doctor Award (2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
26 Years Experience
Loyola University Chicago Stritch School Of Medicine
Graduated in 1992
University Of California At Davis
Dr. Kellee R Clougherty accepts the following insurance providers.
Blue Cross California
- Blue Cross CA PPO Prudent Buyer Small Group
- Blue Cross CA Advantage PPO Preferred DirectAccess Plus
- Blue Cross CA PPO Prudent Buyer Individual
- Blue Cross CA PPO Prudent Buyer Large Group
- Blue Cross CA Pathway X PPO
- Blue Cross CA Select PPO
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- CIGNA Southern CA Value
- Cigna Southern CA Select
Locations & Directions
Dr. Kellee R Clougherty is similar to the following 3 Doctors near Laguna Niguel, CA. |
Billable Medical Code for Dermatophytosis of Nail
Diagnosis Code for Reimbursement Claim: ICD-9-CM 110.1
Code will be replaced by October 2015 and relabeled as ICD-10-CM 110.1.
Onychomycosis is also known as dystrophic onychomycosis, onychomycosis, onychomycosis (nail fungal infection), onychomycosis/dystrophy, and total dystrophic onychomycosis. This applies to dermatophytic onychia, onychomycosis, and tinea unguium.
Onychomycosis Definition and Symptoms
Onychomycosis is a fungal infection in the toe or fingernails that can include all components of the nail. The infection begins underneath the nail and causes the nail to look opaque and brittle. Symptoms include thickening of the nail, pain when standing, and a sensation of prickling or tingling in the toe or finger. |
More than 22 million Americans of all ages have asthma. Prepare to talk to your doctor about symptoms, diagnosis and treatment options.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- Pregnancy Facts about pregnancy, including symptoms you can expect to have.
- Ragweed Allergy Ragweed allergy facts: symptoms, how to avoid it, trigger foods.
- Seasonal Allergies Facts about seasonal allergies, the different types and the symptoms.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Book Online Now
Dr. Domenico Zanolin has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Domenico Zanolin has the following 5 expertise
- Pediatric Diabetes
Dr. Domenico Zanolin has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Domenico Zanolin is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 2 of 10
Patients' Choice Award (2012, 2013, 2014)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2012, 2013, 2014)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
On-Time Doctor Award (2014)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
33 Years Experience
Universita Degli Studi Di Padova
Graduated in 1985
University Hospital Suny Stony Brook
Dr. Domenico Zanolin accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Elect Choice EPO
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna NYC Community Plan
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS MA Blue Care Elect PPO
- BCBS MA Preferred Blue PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- Connecticare Flex Connecticut
- Empire Blue Priority EPO
- Empire HMO
- Empire PPO
- Empire Prism EPO Blue Priority
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
MVP Health Plan
- MVP Preferred PPO
- Multiplan PPO
- PHCS PPO
- Oxford Metro
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsSuffolk Pediatric Associates Pc, 1111 Montauk Hwy Ste 104, West Islip, NY
Dr. Domenico Zanolin is similar to the following 3 Doctors near West Islip, NY. |
Get the facts about bipolar disorder, including the different types and symptoms of each.
- Bipolar Disorder Facts about bipolar disorder, including different types and symptoms.
- ADHD Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Adult ADHD Facts about attention deficit hyperactivity disorder (ADHD) in adults.
- Alzheimer's Disease Facts about Alzheimer’s Disease, including the symptoms and stages.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Chronic Pain Facts about chronic pain, including body parts most commonly affected.
- Clinical Depression Clinical depression facts; symptoms & other depressive disorders.
- Depression Facts about depression, including the symptoms of the condition.
- Diabetic Neuropathy Facts about diabetic neuropathy, including the symptoms and doctors.
- Epilepsy Facts about epilepsy, including different types, symptoms and causes.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Book Online Now
Dr. Dena B Dubal has the following 2 specialties
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
A neurologist is a physician who diagnoses and treats disorders of the nervous system which is comprised of the brain, spinal cord and nerves. These doctors do not perform surgery, but refer patients to neurological surgeons when they determine that surgical intervention is necessary.
Some of the conditions that neurologists diagnose and treat are epilepsy, aneurysms, hydrocephalus, Parkinson's disease, multiple sclerosis, stroke, spinal disc herniation, and spinal disease.
In addition to using diagnostic tests like MRI, CT scans, EEG and EMG, neurologists also employ neurological testing to gauge muscle strength and movement, balance, reflexes, sensation, memory, speech, and other cognitive abilities.
Dr. Dena B Dubal has the following 10 expertise
- Multiple Sclerosis (MS)
- Migraine Disorder
- Middle Cerebral Artery Infarction
- Brain Ischemia
- Alzheimer's Disease
- Nerve Conduction Studies
Dr. Dena B Dubal has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 5 of 8
Patients' Choice Award (2008, 2009, 2010, 2011)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2010)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
15 Years Experience
University Of Kentucky College Of Medicine
Graduated in 2003
Dr. Dena B Dubal accepts the following insurance providers.
- Aetna Basic HMO
- Aetna Choice POS II
- Aetna HMO
- Aetna HMO Deductible Plan CA only
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- Aetna Vitalidad Plus CA con Aetna
BCBS Blue Card
- BCBS Blue Card PPO
- Health Net CA HMO Employer Group
- Health Net CA Individual and Family PPO
- Health Net CA PPO
- Humana Choice POS
- Multiplan PPO
- PHCS PPO
- PHCS PPO Kaiser
Locations & DirectionsUcsf Medical Center, 505 Parnassus Ave, San Francisco, CA
Dr. Dena B Dubal is similar to the following 3 Doctors near San Francisco, CA. |
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Support World Kidney Day with Proper Coding
On World Kidney Day, March 8, take a moment to refresh your understanding of chronic kidney disease (CKD) and how to properly code this unfortunate diagnosis.
One in seven Americans has CKD — more women than men: CKD affects 16 percent of women and 13 percent of men, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health (NIH). Most people with this condition don’t know they have it.
Stages of Chronic Kidney Disease
CKD is a mixed bag of conditions characterized by changes in kidney structure and function. The manifestation of these conditions is based on the underlying cause and severity of the disease.
According to the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative (NKF KDOQI) for renal diseases, the list of clinical parameters shown in the table below is provided for staging CKD. The provider must document the stage and be queried in the absence of documentation.
|Stage||Description||GFR (mL/min/1.73 m2)|
|1||Kidney damage with normal or ↑ GFR||≥ 90|
|2||Kidney damage with mild ↓ GFR||60 – 89|
|3||Moderate ↓ GFR||30 – 59|
|4||Severe ↓ GFR||15 – 29|
|5||Kidney failure||< 15 (or dialysis)|
|Chronic kidney disease is defined as either kidney damage or < 60 mL/min/1.73 m2 for ≥ 3 months. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.|
Coding the Stages of CKD
The ICD-10-CM code is assigned to depict the documented severity (stage) of CKD:
- N18.1 Chronic kidney disease, stage 1
- N18.2 Chronic kidney disease, stage 2 (mild)
- N18.3 Chronic kidney disease, stage 3 (moderate)
- N18.4 Chronic kidney disease, stage 4 (severe)
- N18.5 Chronic kidney disease, stage 5
Code N18.6 End stage renal disease is assigned only when the provider has documented end-stage renal disease (ESRD). Encounters where both a stage of CKD and ESRD are documented, report N18.6, only.
Coding Cause-and-Effect Relationships
CKD is often due to nephrotic syndrome. Nephrotic syndrome is associated with overexcretion of protein in the urine (proteinuria); edema of lower extremities, face, and abdomen; and damage to the blood vessels of the nephron. Only assign the code for nephrotic syndrome when the physician specifically states the patient has it. See N04.1-N04.9 in ICD-10-CM for the appropriate code assignment.
Hypertension is one of the leading causes of CKD. ICD-10-CM presumes a cause-and-effect relationship between hypertension and CKD. You are directed to combine the two when the chart indicates the patient has both hypertension and CKD. The exception to this rule is when the provider specifically states the two are not related.
Code I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease or I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease is assigned with the appropriate N18.x code.
Healthy lifestyle changes can help prevent and manage kidney disease and its main causes: diabetes and high blood pressure. Given the impact of kidney disease on women, the NIDDK encourages all women to learn about risk factors and talk with healthcare professionals. Taking action now can help protect your kidneys. Here are ways to reduce your risk:
- Choose healthier foods, such as fresh fruits, fresh or frozen vegetables, whole grains, and low-fat or fat-free dairy products.
- Be physically active for 30 minutes or more on most days.
- Reduce screen time, and aim for 7 to 8 hours of sleep each night.
- Join family, friends, or coworkers in encouraging each other to stick to a healthy routine.
- Use the NIH Body Weight Planner to help achieve and stay at a healthy weight.
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Dr. Neil P Fullan has the following 2 specialties
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
- Adolescent Medicine
Adolescent specialists are doctors who have advanced training in the health issues that adolescents face. These physicians deal with issues like the onset of puberty, reproductive health, eating disorders, irregular periods, mood changes, drugs and pressures from home and school. For girls entering adulthood, adolescent specialists can act as both pediatrician and gynecologist, so they only have to see one doctor for all their needs.
Dr. Neil P Fullan has the following 11 expertise
- Sexually Transmitted Diseases
- Birth Control
- Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
- Sleep Disorders
- Eating Disorders
- Depressive Disorder
- Substance Abuse
Dr. Neil P Fullan has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
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Dr. Fullan treated both of my sons. One of my sons saw Dr. Fullan from age five to age nineteen. My other son saw Dr. Fullan from age eleven to age twenty three. Both of my sons have ADD. One of my sons has Bipolar Depression and Asperger's Syndrome, in addition to ADD. Dr. Fullan was like part of our family. He always spent an adequate amount of time with us and his treatments were successful. If it was not for Dr. Fullan our son with multiple diagnoses would not be the functional, hardworking, and happy adult that he is. I am not going to say that there were not ups and downs because there were. There always are ups and downs with mental illness, such as medication changes, and sometimes hospitalizations. I recommend Dr. Fullan all the time to parents. He was our rock for so many years.
When I was 13, Dr. Fullan tried to place a diagnosis of Anti-social Personality Disorder into my files, despite it having an age requirement of 18. A lazy attempt, as I had PTSD, ADHD, a neurologically-based anxiety disorder, and moderately abusive parents who were going through a divorce.Dr. Fullan also broke the confidentiality agreement numerous times, encouraging me to tell him things in confidence and then informing my parents of specific details. I was physically and emotionally abused off of what he revealed to my parents.I would never bring my child to him. Children seeking treatment, especially those with PTSD, need a safe environment where their words will not be betrayed.
Our two sons have been under Dr. Fullan's care for approx. 8 years. Each had issues of great concern. Our eldest has depression, severe OCD, and anxiety disorder. Our younger son has ADHD, depression, and anxiety disorder. Both were diagnosed correctly by Dr. Fullan who, with counseling, medication, and genuine care and concern, changed our troubled sons into happy, well-adjusted, on-track young gentlemen. Dr. Fullan's gifts of a deeply caring nature, acute listening skills, discerning treatment, and follow-up regarding his patient's overall well-being, make him an amazing physician. Dr. Fullan's rapport gained our sons' trust and respect and provided a safe place for them to share. I have no doubt that without him, one of our sons probably wouldn't be with us. We owe him our lives for having saved those of our sons. God gifted us with Dr. Fullan who is the best pediatric/adolescent psychiatrist in the world, and we are forever grateful parents to this awesome man!
On-Time Doctor Award (2015)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
36 Years Experience
Rush Medical College Of Rush University Medical Center
Graduated in 1982
University Of Wisconsin Hospital
Dr. Neil P Fullan accepts the following insurance providers.
- Aetna Signature Administrators PPO
- Anthem Blue Access PPO
- Anthem Blue Preferred HMO
- Anthem Blue Preferred Plus POS
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL PPO
Network Health Plan
- Network Health Plan HMO POS
- Network Health Plan Individual
- WPS Group
Locations & DirectionsAnima Family Counselnig Llc, 2475 University Ave Ste A, Green Bay, WI
Take a minute to learn about Dr. Neil P Fullan, MD - Adolescent Medicine in Green Bay, WI, in this video.
Dr. Neil P Fullan is similar to the following 3 Doctors near Green Bay, WI. |
Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
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About Dr. Marjorie A Alvir
Dr. Marjorie A Alvir, DO is a Doctor primarily located in Arcadia, CA. She has 13 years of experience. Her specialties include Family Medicine. She speaks English.
Dr. Marjorie A Alvir has the following 1 specialty
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. Marjorie A Alvir has the following 10 expertise
- Preventive Medicine
- Weight Loss
- Family Planning
- Women's Health
- Adolescent Medicine
Dr. Marjorie A Alvir has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
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I happen to be a physician and went to her due to the other doctors being fully booked. Bad mistake. I have a family history of high cholesterol. My blood work came back as doubled the normal range, which is concerning to a 30 year old. Her solution was for me to go on a diet and workout. If she didn't look at her computer the entire time along with not obtaining a case history, she would know that I run 5-8 miles daily along with strength training for the last 8 years. I don't eat red meat and monitor all my nutrients. Very poor bedside manners. How is she even a physician?
It's ironic that Dr. Alvir is smiling in her photo because I've never actually seen her smile.In my experience she has been rude, has not listened at all, ordered tests for me that I did not need, but refused to order tests I requested based on a genetic condition. The last appointment she stared at her computer 90% of the time, and then abruptly announced, "I don't have time for this" and left the room to deal with other patients. I had to wait over 20 minutes for her to come back, on top of the original 20 minutes I had to wait just to see her initially.
Very insecure, short, uninformed. Would rather do nothing unless the issue is extreme and then she doesn't follow through with treatment. Inconsistent answers from one visit to another. Second guesses herself and bases decisions on partial information because she tunes out the patient. She even WALKED OUT of the room as I was asking her questions because she felt it was taking too long and instead of wrapping it up, she walked out.It is a fight just to get her to treat a condition. The wait is forever for such a short time you get with her. She even told me once that "I can only bring 2 issues up per visit!!"STAY AWAY from her and any other practitioner at hartland family care. it is a waste of money and time. Even the office staff makes you feel like they are doing YOU a favor when they do their job. They pass the buck any chance they can.
13 Years Experience
Michigan State University College Of Human Medicine
Graduated in 2005
Dr. Marjorie A Alvir accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna HMO Deductible Plan CA only
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
Blue Cross California
- BC CA California Care Small Group HMO
- Blue Cross CA California Care Large Group HMO
- Blue Cross CA PPO Prudent Buyer Large Group
- Blue Cross CA Pathway X PPO
- Blue Cross CA Select HMO
- Blue Cross CA Select PPO
- Blue Cross CA Select Plus HMO
- Blue Cross CA Vivity
Blue Shield California
- Blue Shield CA Access Plus HMO
- Blue Shield CA Access Plus Savenet
- Blue Shield CA Bronze Full PPO 4500
- Blue Shield CA Local Access Plus HMO
- Blue Shield CA PPO
- Blue Shield CA Platinum Access+ HMO 25
- Blue Shield CA Platinum Local Access + HMO 25
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- Cigna Southern CA Select
- First Health PPO
- Health Net CA HMO Employer Group
- Health Net CA HMO SmartCare
- Health Net CA HMO Whole Care Network
- Health Net CA Individual and Family PPO
- Health Net CA PPO
- Health Net SmartCare Large Group
- Health Net SmartCare Small Group
- Humana Choice POS
LA Care Health
- Multiplan PPO
- PHCS PPO
- PHCS PPO Kaiser
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsHealthcare Partners Medical Group, 450 E Huntington Dr, Arcadia, CA
Dr. Marjorie A Alvir is similar to the following 3 Doctors near Arcadia, CA. |
Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- HIV/AIDS The differences between HIV & AIDS; signs, symptoms & complications.
- Lupus Get the facts about lupus, including symptoms, risk factors, and the different types.
- Menopause Facts about menopause, including the stages, symptoms, and types.
- Shingles Facts about shingles, including symptoms & possible long-term effects.
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About Dr. Essam A Girgawy
Dr. Essam A Girgawy, MD is a Doctor primarily located in Kingwood, TX, with other offices in Houston, TX and Houston, TX . He has 38 years of experience. His specialties include Infectious Disease and Internal Medicine. Dr. Girgawy is affiliated with Memorial Hermann Northeast Hospital. Dr. Girgawy has received 1 award. He speaks English.
Dr. Essam A Girgawy has the following 2 specialties
- Infectious Disease
An infectious disease specialist has specialized training in the diagnosis and treatment of contagious diseases.
Infectious diseases, also known as contagious or transmissible diseases, are those that stem from pathogen from a host organism. These infections may spread to other carriers through physical touch, airborne inhalation, bodily fluids or contaminated foods.
Infectious disease specialists identify whether the disease is caused by bacteria, a virus, a fungus or a parasite often through blood tests and then determine what course of treatment, if any, is necessary.
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Essam A Girgawy has the following 8 expertise
- AIDS/HIV (Acquired Immunodeficiency Syndrome)
- Human Immunodeficiency Virus (HIV/AIDS)
- Hepatitis C
- HIV Infections
Dr. Essam A Girgawy has 0 board certified specialties
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Dr Girgawy is the most special doc. He always puts the patient's welfare and feelings first. He carefully explains all procedures and options. He is extremely compassionate and caring. He consults in person and by phone for many patients in numerous hospitals and sees patients late into the evenings if necessary. His thorough knowledge has saved my husband's life.
My husband was billed for services that were unjust. When I questioned what services Dr. Girgawy had provided, I was told consultation fee. When I said he did not see him, I was told he may have gone in his room or looked at his files. This doctor charged over $100; my husband's GP does more and charges much less.
Patients' Choice Award (2014)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Dr. Girgawy is affiliated (can practice and admit patients) with the following hospital(s).
38 Years Experience
University Of Cairo
Graduated in 1980
University Of Texas Health Science Center
Dr. Essam A Girgawy accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS TX BlueChoice
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana HMO
- Humana HMO Premier
- Humana Houston HMOx
- Humana National HMO
- Humana National POS
- Humana Preferred PPO
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & Directions
Dr. Essam A Girgawy is similar to the following 3 Doctors near Kingwood, TX. |
Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- Pregnancy Facts about pregnancy, including symptoms you can expect to have.
- Ragweed Allergy Ragweed allergy facts: symptoms, how to avoid it, trigger foods.
- Seasonal Allergies Facts about seasonal allergies, the different types and the symptoms.
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About Dr. Valerie A Kimball
Dr. Valerie A Kimball, MD is a Doctor primarily located in Evanston, IL. Her specialties include Pediatrics. She speaks English.
Dr. Valerie A Kimball has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Valerie A Kimball has the following 9 expertise
- Pediatric Diabetes
- Child Development
- Newborn Medicine (Neonatology)
Dr. Valerie A Kimball has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Valerie A Kimball is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
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Loyola University Medical Center
Dr. Valerie A Kimball accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL Blue Advantage HMO
- BCBS IL PPO
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- HealthLink PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Multiplan PPO
- PHCS PPO
- PriorityHealth Priority PPO
- UHC Choice Plus POS
- UHC Options PPO
Locations & DirectionsTraismans Benuck Merens And Kimball, 1950 Dempster St, Evanston, IL
Take a minute to learn about Dr. Valerie A Kimball, MD - Pediatrics in Evanston, IL, in this video.
Dr. Valerie A Kimball is similar to the following 3 Doctors near Evanston, IL. |
Get the facts about adult asthma, including who gets it, what triggers it, and how allergies can affect it.
- Lung Cancer Get lung cancer facts, including risk for developing it.
- Adult Asthma Facts for adult asthma, including triggers & how allergies affect it.
- Allergic Asthma Facts about allergic asthma; who gets it & the most common symptoms.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Coronary Heart Disease Get the facts about coronary heart disease.
- Cystic Fibrosis Facts about cystic fibrosis, including the symptoms of the condition.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
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About Dr. Mohammad H Madantschi
Dr. Mohammad H Madantschi, MD is a Doctor primarily located in Peoria, AZ, with other offices in Phoenix, AZ and Glendale, AZ (and 1 other location). His specialties include Pulmonary Disease and Critical Care Medicine. Dr. Madantschi has received 3 awards. He speaks English.
Dr. Mohammad H Madantschi has the following 2 specialties
- Pulmonary Disease
A pulmonologist is a physician who specializes in the diagnosis and treatment of conditions related to the lungs and respiratory tract.
These specialists are similar to critical care specialists in that their patients often require mechanical ventilation to assist their breathing.
Pulmonologists diagnose and treat patients with conditions such as asthma, cystic fibrosis, asbestosis, pulmonary fibrosis, lung cancer, COPD, and emphysema. Exposure and inhalation of certain toxic substances may also warrant the services of a pulmonologist.
Some of the tools and tests pulmonologists use to diagnose a patient are a stethoscope in order to listen for abnormal breathing sounds, chest X-rays, CT scans, blood tests, bronchoscopy, and polysomnography.
- Critical Care Medicine
Also sometimes referred to as intensivists, critical care specialists are physicians with specialized training in the diagnosis and management of life-threatening conditions. Some of these conditions affect vital organs like the heart and lungs, those that make breathing difficult or impossible, and those that affect entire organ systems, like the renal system.
Critical care specialists are typically found in a hospital's intensive care unit where they monitor patients with life-threatening conditions and make determinations as to the best course of treatment.
Dr. Mohammad H Madantschi has the following 13 expertise
- Obstructive Sleep Apnea
- Chest Infection
- Chronic Obstructive Pulmonary Disease (COPD)
- Tuberculosis (TB)
- Central Sleep Apnea
- Intrinsic Sleep Disorders
- REM Sleep Behavior Disorder
- Angiographic Visualization
- Disorders of Excessive Sleepiness (Hypersomnia)
Dr. Mohammad H Madantschi has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
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Dr. Madantchi is an excellent Dr. He is extremely kind, listens to every word you say and explains everything in detail. I just wish I would have found him years ago. I? have a friend that was dying and Dr Madantchi saved his life. He is here today due to the care he provided for my friend. The best in the business in my opinion??????
Compassionate Doctor Recognition (2017, 2018)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
Patients' Choice Award (2017, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
On-Time Doctor Award (2017, 2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Allegheny University Hospitals
Dr. Mohammad H Madantschi accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Savings Plus of AZ
- Aetna Signature Administrators PPO
- Aetna Whole Health Banner Health Network HMO
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- Health Net AZ PPO HSA
- Humana Choice POS
- Humana National POS
- Humana Phoenix HMOx
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Options PPO
Locations & Directions
Dr. Mohammad H Madantschi is similar to the following 3 Doctors near Peoria, AZ. |
In recent years, a number of independent researchers and various government agencies have conducted research on the efficiency, appropriateness, and cost-effectiveness of chiropractic treatment. Several of the important studies are listed below.
U.S. Government Agency Report
A 1994 study published by the U.S Agency for Health Care Policy and Research (AHCPR) and the U.S. Department of Health and Human Services endorses spinal manipulation for acute low back pain in its Clinical Practice Guideline #14. An independent multidisciplinary panel of private-sector clinicians and other experts convened and developed specific statements on appropriate health care of acute low back problems in adults. One statement cited relief of discomfort (low back pain) can be accomplished most safely with spinal manipulation and/or nonprescription medication.
The Manga Report
A major study to assess the most appropriate use of the available health care resources was reported in 1993. This was an outcome study funded by the Ontario Ministry of Health and conducted in hopes of sharing information about ways to reduce the incidence of work related injuries and to address cost-effective ways to rehabilitate disabled and injured workers. The study was conducted by three economists led by University of Ottawa Professor Pran Manga, Ph D. The report of the study is commonly called the Manga Report. The Manga Report overwhelmingly supported the efficacy, safety, scientific validity, and cost-effectiveness of chiropractic for low back pain. Additionally, it found that higher patient satisfaction levels were associated with chiropractic care than with medical treatment alternatives. "Evidence from Canada and other countries suggests potential saving of hundreds of millions annually," the Manga Reports states. "The literature clearly and consistently shows that the major savings from chiropractic management come from fewer and lower costs of auxiliary services, fewer hospitalizations, and highly significant reduction in chronic problems, as well as in levels and duration of disability."
Rand Study on Low Back Pain
A four-phase study conducted in the early 1990's by Rand, one of America's most prestigious centers for research in public policy, science and technology, explored many indications of low-back pain. In the Rand studies, an expert panel of researchers, including medical doctors and doctors of chiropractic, found that:
- Chiropractors deliver a substantial amount of health care to the U.S. population.
- Spinal manipulation is of benefit to some patients with acute low back pain.
- The Rand report marked the first time that representatives of the medical community went on record stating that spinal manipulation is an appropriate treatment for certain low-back pain conditions.
The New Zealand Commission Report
A particularly significant study of chiropractic care was conducted between 1978-1980 by the New Zealand Commission of Inquiry. In its 377 page report to the House of Representatives, the Commission called its study, "probably the most comprehensive detailed independent examination of chiropractic ever undertaken by any country." The general impression...shared by many in the community that chiropractic was an unscientific cult, not to be compared with orthodox medical or paramedical services. By the end of the inquiry the commission reported itself "irresistibly and with complete unanimity drawn to the conclusion that modern chiropractic is soundly-based and a valuable branch of health care in a specialized area..." Conclusions of the Commission's report, based on investigations in New Zealand, United States, Canada, United Kingdom, and Australia stated:
- Spinal manual therapy in the hands of a registered chiropractor is safe.
- Spinal manual therapy can be effective in relieving musculoskeletal symptoms such as back pain and other symptoms known to respond to such therapy, such as migraine.
- Chiropractors are the only health practitioners who are necessarily equipped by their education and training to carry out spinal manual therapy.
- In the public interest and the interest of patients, there must be no impediment to full professional cooperation between chiropractors and medical practitioners.
Florida Workers Compensation Study
A 1998 study of 10,652 Florida workers' compensation cases was conducted by Steve Wolk, Ph.D., and reported by the Foundation for Chiropractic Education and Research. It was concluded that "a claimant with a back related injury, when initially treated by a chiropractor versus a medical doctor, is less likely to become temporarily disabled or if disabled, remains disabled for a shorter period of time; and claimants treated by medical doctors were hospitalized at a much higher rate than claimants treated by chiropractors."
Washington HMO Study
In 1989, a survey administered by Daniel C. Cherkin, Ph.D., and Frederick A. Mac Cornack, Ph D., concluded that patients receiving care from health maintenance organizations (HMO's) within the state of Washington were three times as likely to report satisfaction with care from chiropractors as they were with care from other physicians. The patients were also more likely to believe that their chiropractors were concerned about them.
Utah Workers' Compensation Study
A workers' compensation study conducted in Utah by Kelly B. Jarvis, D.C., Reed B. Philips, D.C., Ph. D., and Elliot K Morris, JD, MBA, compared the cost of chiropractic care to the costs of medical care for conditions with identical diagnostic codes. Results were reported in the August 1991 Journal of Occupational Medicine. The study indicated that costs were significantly higher for medical claims than for chiropractic claims; in addition, the number of work days lost was nearly ten times higher for those who receive medical care instead of chiropractic care.
Patient Disability Comparison
A 1992 article in the Journal of Family Practice reported a study by D.C. Cherkin, Ph.D., which compared patients of family physicians and of chiropractors. The article stated "the number of days of disability for patients seen by family physicians was significantly higher (mean 39.7) than for patients managed by chiropractors (mean 10.8)." A related editorial in the same issue referred to risks of complications from lumbar manipulation as being "very low."
Oregon Workers' Compensation Study
A 1991 report on workers' compensation study conducted in Oregon by Joanne Nyiendo, Ph. D. concluded that the median time loss days (per case) for comparable injuries was 9.0 for patients receiving treatment by a doctor of chiropractic and 11.5 for treatment by a medical doctor.
Stano Cost Comparison Study
A study by Miron Stano, Ph D., reported in the June 1993 Journal of Manipulative and Physiological Therapeutics involved 395,641 patients with neuromusculoskeletal conditions. Results over a two-year period showed that patients who received chiropractic care incurred significantly lower health care costs than did patients treated solely by medical or osteopathic physicians.
Saskatchewan Clinical Research
Following a 1993 study, researchers J. David Cassidy, D.C. and Haymo Thiel, Royal University Hospital in Saskatchewan, concluded that "the treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective."
Wight Study on Recurring Headaches
A 1978 study, conducted by J.S. Wight, D.C. and reported in the ACA Journal of Chiropractic, indicated that 74.6% of patients with recurring headaches, including migraines, were either cured or experienced reduced headache symptomatology after receiving chiropractic manipulation.
1991 Gallop Poll
A 1991 demographic poll conducted by the Gallop Organization revealed that 90% of chiropractic patients felt their treatment was effective; more than 80% were satisfied with that treatment; and nearly 75% felt most of their expectations had been met during their chiropractic visits.
1990 British Medical Journal
A study conducted by T.W. Meade, a medical doctor, and reported in the June 2, 1990, British Medical Journal concluded after two years of patient monitoring, "for patients with low-back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management."
Virginia Comparative Study
A 1992 study conducted by L.G. Schifrin, Ph. D., provided economic assessment of mandated health insurance coverage for chiropractic treatment within the Commonwealth of Virginia. As reported by the College of William and Mary and the Medical College of Virginia, the study indicated that chiropractic provides therapeutic benefits at economical costs. The report also recommended that chiropractic be a widely available form of health care.
1992 American Health Policy Report
A 1992 review of data from over 2,000,000 users of chiropractic care in the U.S. reported in the Journal of American Health Policy, stated that "chiropractic users tend to have substantially lower total health care costs" and "chiropractic care reduces the use of both physician and hospital care."
1985 University of Saskatchewan Study
In 1985 the University of Saskatchewan conducted a study of 283 patients "who had not responded to previous conservative or operative treatment" and who were initially classified as totally disabled. The study revealed that "81%...became symptom free or achieved a state of mild intermittent pain with no work restrictions" after daily spinal manipulations were administered.
Landmark Legal Decision Supports Chiropractic
Further validation of chiropractic care evolved from an antitrust suit which was filed by four members of the chiropractic profession against the American Medical Association (AMA) and a number of other health care organizations in the U.S. (Wilk et al v. AMA et al, 1990). Following eleven years of litigation, a federal appellate court judge upheld a ruling by U.S. District Court Judge Susan Getzendanner that the AMA had engaged in a "lengthy, systematic, successful and unlawful boycott" designed to restrict cooperation between MD's and chiropractors in order to eliminate the profession of chiropractic as a competitor in the U.S. health care system. Judge Getzendanner rejected the AMA's patient care defense and cited scientific studies which implied that "chiropractic care was twice as effective as medical care in relieving many painful conditions of the neck and back as well as related musculoskeletal problems." Since the court's findings and conclusions were released, an increasing number of medical doctors, hospitals, and health care organizations in the U.S. have begun to include the services of chiropractors. |
Ten Things You Should Know about How Health Insurance Works
You probably understand many of the key concepts of health insurance, but you not know as much as you think. Health insurance is a financial product, and like most other financial products, it is a complex instrument that has been developed over centuries. The modern incarnation of health insurance is governed by both industry standards as well as state and federal regulations, making it both difficult to understand and beneficial in some surprising ways.
1. You can’t be denied a policy because you’re sick—Under the Affordable Care Act of 2010, the federal government made it illegal for insurance companies to refuse you a health policy because you are ill. Likewise, it is also illegal for them to offer you a policy at a higher price because you have a health condition. However, they may adjust prices depending on your age and geographic location.
2. Insurers have to explain why they rejected a claim—If your insurer refuses to pay a claim, you are legally entitled to a reason why. If you still think that you should be reimbursed, you have the option of pursuing an internal appeal (through the insurance company) or an external review (an independent third party makes a judgment).
3. If you don’t get health insurance, you may have to pay a financial penalty—When Congress passed the Affordable Care Act of 2010, they included a component called the Individual Mandate. This part of the law requires that all Americans with a certain amount of income must get covered or pay a penalty which in 2017 was $695 or 2.5 percent of your income, whichever is higher.
4. Health plans must include free preventive care—Many people don’t realize that their health insurance grants them many free preventive care services. This includes
- Blood pressure screening
- Cholesterol screening
- Diet counseling
- Depression screening
- Diabetes screening
- Hepatitis B screening
- Immunization vaccines
- Lung cancer screening
- STD counseling
- Obesity screening and counseling
5. Avoid lapses in coverage—If you have insurance through your employer and leave your job, make sure to re-enroll in a health plan within 63 days. That is the deadline to sign up for COBRA, the federally sponsored health plan extension that may provide coverage for an additional 18 to 36 months. This is also the maximum amount of time you have to enroll in a new health plan without having to divulge any health conditions; after this time period a new employer insurer has the right to inquire.
6. Don’t settle for your employer health plan—You may not realize it, but you don’t have to get coverage through your employer. Closely examine the coverage terms to see if you are getting the most for your money. If you are enrolled in a high deductible policy, you may have to pay thousands of dollars out of pocket before your insurer starts to kick. If you are young and healthy you may find better options elsewhere, because group plans base premiums on the entire group’s health and age.
7. Deductibles in health plans don’t preempt benefits—Unlike your home or auto insurance policy where you must pay the deductible before enjoying any of the policy’s benefits, a health insurance policy may provide you some benefits even if you haven’t met your annual deductible limit. These benefits may include discounts for prescription drugs, free annual checkups or preventive care services.
8. Low premiums may not mean low overall cost—Like most things, with health insurance, you are likely to get what you pay for. If you want a low premium policy, you will probably have to pay in other ways including higher deductibles or other out-of-pocket expenses. In the long run, if you encounter a major health crisis, or even a few minor ones, you may wish that you had gone with a plan with a higher premium that offered benefits. Take into consideration how often you and your family are likely to use medical services before you finally decide on a health plan.
9. You may use government subsidies to pay for health insurance—One of the most important features of the Affordable Care Act of 2010 was that it helped many Americans get enrolled in a health plan by helping to pay for monthly premiums. If your household makes between 100 percent and 400 percent of the federal poverty level, then you probably qualify for these ACA-sponsored subsidies. If you qualify, you may apply hundreds of dollars a month to your monthly premium, saving thousands of dollars annually. To use these subsidies, you must apply through one of the state or federal health insurance marketplaces and enroll in one of the plans available there. You must also verify your income by filing a tax return for any year are enrolled in a ACA plan.
10. Choose a network that suits your lifestyle—When you are shopping for a health plan, look closely at the three letters denoting the type of network. These should be HMO, PPO, EPO, or POS. An HMO is the most restrictive, in that you can only see providers in your network, but these plans are usually the most cost effective. A PPO plan allows you to see doctors out of network and has less limitations on what kind of doctors you may see, but these are often more expensive. EPO and POS plans are hybrids of HMO and PPO plans.
Health insurance, at its most basic, is simple to understand; you pay an insurer to help protect you from the financial consequences of a medical emergency. However, there is often much more involved when you examine the finer points of your health plan. If you would like to learn more about your current health insurance policy or would like to know what other health plans are available to you, you may find answers with one of the experienced insurance agents at Boost Health Insurance.
Find the best plans in Los Angeles, CA
Speak to one of our licensed health insurance agents. |
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