E&M Nuts and Bolts Part I History and Exam. Presented by Kerin Draak, MSN, WHNP-BC, CPC, CEMC, COBGC

Transcription

1 E&M Nuts and Bolts Part I History and Exam Presented by Kerin Draak, MSN, WHNP-BC, CPC, CEMC, COBGC 1

2 Disclaimer The Wisconsin Medical Society continuing education publications and seminars are presented with the understanding that the Wisconsin Medical Society and the speakers do NOT render any legal, accounting or other professional service. Due to the rapidly changing nature of law and healthcare, information contained in the publication or seminar material may be outdated. As a result, an attendee using the Wisconsin Medical Society or a speakers material must always research original sources of authority and update the information to ensure accuracy when dealing with a specific client s legal matters. 2

3 Objectives Participants will understand the documentation requirements for the three key components of Evaluation & Management code selection; History, Exam and Medical Decision Making. Participants will understand how the three key components are used to support the coding of New vs Established E/M levels of service. Participants will know how to apply either the 1995 or the 1997 Documentation Guidelines for coding selection. 3

4 Evaluation & Management Code Selection Patient Type Setting of the Service Level of the E/M Performed 4

5 Patient Type New Patient A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. (CPT, 2016) 5

6 Patient Type Established Patient An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. (CPT, 2016) 6

7 Setting of Services Office/Outpatient Hospital Consultations Emergency Dept. Critical Care Nursing Facility Domiciliary, Rest Home or Custodial Non-Face-to-Face Transitional Care Home Services Prolonged Services Case Management Care Plan Oversight Preventative Medicine Newborn Work/Medical Disability Inpatient Neonatal Complex Chronic Care Coordination 7

8 Level of E/M Service History HPI ROS PFSH Medical Decision Making Exam 1995 or 1997 Time 8

9 Components of E/M Services Seven components used in defining the levels of E/M Services History Examination Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time KEY Contributing 9

10 Three Key Components History Examination Medical Decision Making 10

11 History Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family and/or Social History (PFSH) 11

12 History The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s). (CPT, 2016) 12

13 History: HPI A chronological description of the development of the patient s present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, timing, context, modifying factors and associated signs and symptoms significantly related to the presenting problem(s). (CPT, 2016) 13

14 History: HPI Location: where in/on the body the problem, symptom or pain occurs Area of body, bilateral, unilateral, left, right, anterior, posterior, upper, lower, diffuse or localized, fixed or migratory, radiating to other areas. Example left lower leg 14

15 History: HPI Quality: an adjective describing the type of problem, symptom or pain Dull, sharp, throbbing, constant, itching, stabbing, red or swollen, cramping, shooting, scratchy. 15

16 History: HPI Severity: patient s verbal descriptions as to the degree/extent of the problem, symptom or pain; pain scale 0 to 10, comparison of the current problem, symptom or pain to previous experiences. 16

17 History: HPI Duration: how long the problem, symptom or pain has been present or how long the problem, symptom or pain lasts Since last night, for the past week, until today, it lasts for 2 hours. 17

18 History: HPI Timing: when the problem, symptom or pain occurs or an indication of the number of occurrences or frequency of the problem, symptom or pain. Constant or comes and goes 18

19 History: HPI Context: what actions/circumstances causes the problem, symptom or pain to occur/worsen Fell going down the stairs 19

20 History: HPI Modifying Factors: actions/activities taken to improve the problem, symptom, or pain and its outcome Pain relieved with Tylenol, no relief with Ibuprofen, it felt better/worse when I 20

21 History: HPI Associated Signs & Symptoms: other signs/symptoms that occur when the problem, symptom or pain occurs Generalized symptoms (constitutional), frequency and urgency with urination, headache with blurred vision, back pain leads to numbness and tingling down the leg. 21

22 Levels of HPI Brief 1995 and 1997 Documentation Guidelines DG: The medical record should describe one to three elements of the present illness (HPI). Extended 1995 Documentation Guidelines The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities Documentation Guidelines The medical record should describe at least four elements of he present illness (HPI), or the status of at least chronic or inactive conditions. 22

23 Review of Systems An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. (CPT, 2016) DG: The patient s positive responses and pertinent negatives for the system related to the problem should be documented. 23

24 History: Review of Systems Constitutional symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic 24

25 History: Review of Systems Constitutional: weight loss/gain, fever, weakness, fatigue Eyes: eyestrain, excessive tearing or pain, any visual disturbances, blurred or double vision, floaters, redness, swelling, sensitivity to light NOTE: Wears glasses is a statement of fact, not a sign or symptom 25

26 History: Review of Systems Ears, Nose, Mouth & Throat: sensitivity to noise, hearing loss, discharge, tinnitus, vertigo, dizziness, feeling of fullness NOTE: Wears hearing aides is a statement of fact, not a sign or symptom 26

27 History: Review of Systems Cardiovascular: chest pain, palpitations, irregular pulse, edema, faintness, leg pain when walking, coldness or numbness in extremities, hair loss on legs, color changes in fingers or toes 27

28 History: Review of Systems Respiratory: chronic cough, hemoptysis, dyspnea, wheezy/noisy respiration, sputum (color/quantity) 28

29 History: Review of Systems Gastrointestinal: indigestion/pain associated with eating, appetite, thirst, nausea, vomiting, hematemesis, rectal pain and/or bleeding, heartburn, change in bowel habits, diarrhea, constipation, food intolerance, flatus, hemorrhoids, or jaundice 29

30 History: Review of Systems Genitourinary: frequent/painful urination, nocturia, pyuria, hematuria, incontinence, flank pain, genital sores, decreased libido Female: regularity, dysmenorrhea, menorrhagia/metrorrhagia, vaginal discharge, dyspareunia, menopausal symptoms Male: impotence, discharge from penis, testicular pain/masses 30

31 History: Review of Systems Musculoskeletal: muscle pain/cramping, weakness, motor activity limitations, twitching, joint stiffness/deformity, noise with joint movement, chronic backache, redness, swelling 31

32 History: Review of Systems Integumentary: rashes, h/o itching, skin reactions to hot/cold, sores, color changes of lesions/moles, changes in nail color/texture Breast: nipple discharge, breast pain, tenderness or swelling. 32

33 History: Review of Systems Neurological: sensory disturbances, motor disturbances including problems with gait, balance or coordination, tremor or paralysis, headaches-duration, severity, character and location, fainting or unconsciousness, memory loss, hallucinations, disorientation, speech or language dysfunction, tingling, weakness 33

34 History: Review of Systems Psychiatric: depressed mood, nervousness, insomnia, nightmares, headache 34

35 History: Review of Systems Endocrine: heat/cold intolerance, increased sweating, thirst, hunger or urination, changes in hair or skin texture, unexplained changes in weight 35

36 History: Review of Systems Hematologic/Lymphatic: easy bruising, bleeding tendencies, or fatigue, low platelet count, unexplained swollen glands 36

37 History: Review of Systems Allergic/Immunologic: allergies, including eczema, any hives and/or itching, frequent sneezing, chronic clear nasal discharge, recurrent infections. Note: Documenting Allergy to Sulfa is a fact and part of Past Medical History 37

38 Levels of ROS Problem Pertinent DG: The patient s positive responses and pertinent negatives for the system related to the problem should be documented. (1 system) Extended DG: The patient s positive responses and pertinent negatives for two to nine systems should be documented. (2 to 9 systems) 38

39 Levels of ROS Complete DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating a system was negative is permissible. In the absence of such a notation, at least ten systems must be individually documented. ( 10 systems) 39

40 History: Review of Systems It is permissible in a complete ROS for the remaining systems where there are no pertinent responses to make a notation indicating all other systems are negative. 40

41 Caution!!! The term non-contributory is ambiguous some providers take it to mean the system was not relevant, therefore was not reviewed while other providers take it to mean that the system was reviewed, but had no pertinent findings to be reported. Avoid using the term non-contributory. 41

42 History: PFSH Past history Patient s past experiences with illnesses, operations, injuries, and treatments Family history A review of medical events in the patient s family, including diseases which may be hereditary or place the patient at risk Social history An age appropriate review of all past and current activities 42

43 History: Past Past History Prior major illnesses and injuries Prior operations Prior hospitalizations Current medications Allergies (eg, drug, food) Age appropriate immunization status Age appropriate feeding/dietary status 43

44 History: Family Family The health status or cause of death of parents, siblings, and children Specific diseases in the family related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review Diseases of family members which may be hereditary or place the patient at risk 44

45 History: Social Social History Marital status and/or living arrangements Current employment Occupational history Use of drugs, alcohol, and tobacco Level of education Sexual history Other relevant social factors 45

46 History: PFSH NGS: For the family history, will NGS accept noncontributory? ANSWER: The family history includes the age of parents and siblings (if alive) and their current health status, or their age and cause of death if they are deceased. Documentation should also reference diseases related to problems identified in the Chief Complaint and/or ROS. In addition, documentation should describe the patient at risk. 46

47 Levels of PFSH Pertinent DG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH. Complete DG: At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office/outpatient services, established patient; emergency department; subsequent nursing facility care, domiciliary care, established patient; and home care, established patient. 47

48 Levels of PFSH Complete DG: At least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office/outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and home care, new patient. 48

49 Documentation Guidelines DG: A ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by: Describing any new ROS and/or PFSH information or noting there has been no change in the information; and Noting the date and location of the earlier ROS and/or PFSH. 49

50 Documentation Guidelines DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. 50

51 Documentation Guidelines DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient s condition or other circumstance which precludes obtaining a history. 51

52 History Prob Foc Exp Prob Foc Detail HPI status of chronic conditions 3 3 Comp HPI elements Brief Brief Extend Extend Location Severity Quality Duration Timing (1-3) (1-3) ( 4) ( 4) Context Modifying Factors Associated S/S ROS Constitutional Eyes ENMT Cardio Resp GI GU MS Skin Neuro Psych None Prob Pert (1) Extend (2-9) Comp ( 10) Endocrine Hem/Lymph Allerg/Immun PFSH Past: Prior illness/injuries/operations/hosp; meds, allergies, immunization/dietary status Family: Health status or cause of death of parents, sib., children; review of med. events in pt s family Social: Marital status, employment, level of educ., use of drugs/alcohol/tob., sexual hx None None Pert Est. 1 New 1 Comp Est. 2 New 3 52

53 Examination The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s). (CPT, 2016) Currently, both the 1995 and 1997 E/M guidelines are acceptable for documentation of physical examination. 53

54 1995 Examination Guidelines 54

55 Examination-Organ Systems Constitutional Eyes Ears, Nose, Mouth, and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic, Lymphatic, and Immunologic 55

56 Examination- Body Areas Head, including the face Neck Chest, including breast and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity 56

57 Types of Examinations Problem Focused A limited examination of the affected body area or organ system (one body area or system related to the problem). Expanded Problem Focused A limited examination of the affected body are or organ system and other symptomatic or related organ system(s) (additional systems up to total of seven). 57

58 Types of Examinations Detailed An extended examination of the affected body area(s) and other symptomatic or related organ system(s) (additional systems up to total of 7 or more depth than Expanded Problem Focused). Comprehensive A general multi-system examination (8 or more systems of the 12 organ systems) or a complete examination of a single organ system. 58

59 Documentation Guidelines DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of abnormal without elaboration is insufficient. DG: Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described. 59

60 Documentation Guidelines DG: A brief statement or notation indicating negative or normal is sufficient to document normal findings relate to unaffected area(s) or asymptomatic organ system(s). 60

61 1997 Examination Guidelines 61

62 1997 Multi-system Examination Problem Focused Should include performance and documentation of one to five elements identified by a bullet ( ) in one or more organ system(s) or body areas. Expanded Problem Focused Should include performance and documentation of at least six elements identified by a bullet ( ) in one or more organ system(s) or body areas. 62

63 1997 Multi-system Examination Detailed Should include at least 6 organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet ( ) is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet ( ) in two or more organ systems or body areas. 63

64 1997 Multi-system Examination Comprehensive Examination should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed. For each system/area, documentation of at least two elements identified by a bullet is expected. 64

65 1997 Single-System Examination Problem Focused Should include performance and documentation of one to five elements identified by a bullet ( ), whether is a box with a shaded or unshaded border. Expanded Problem Should include performance and documentation of at least six elements identified by a bullet ( ), whether in a box with a shaded or unshaded border. 65

66 1997 Single-System Examination Detailed Examinations other than eye and psychiatric, should include performance and documentation of at least twelve elements identified by a bullet ( ), whether in a box with a shaded or unshaded border. 66

67 1997 Single-System Examination Comprehensive Should include performance of all elements identified by a bullet ( ), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected. 67

68 1995 Exam Vs Exam 1995 Guidelines Exam Components Level of Exam 1997 Guidelines 1 System 2-7 Systems 2-7 Systems 8+ Systems Problem Focused Exp. Problem Detailed Comprehensive 1-5 Bullets 6+ Bullets 12+ Bullets 18+ Bullets 68

69 Medical Decision Making 69

70 Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: The number of possible diagnoses and/or the number of management options that must be considered; The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and 70

71 Medical Decision Making The risk of significant complication, morbidity, and/or mortality, as well as comorbidities, associated with the patient s presenting problem(s), the diagnostic procedure(s) and/or the possible management options. (CPT, 2016) 71

72 Number of Diagnosis or Management Options = A Problem Status No. Pts Result Self-limited or minor (stable, improved or worsening Max =2 1 Est. prob. (to examiner); stable, improved 1 Est. prob. (to examiner); worsening 2 New prob. (to examiner); no add l workup Max =1 3 New prob (to examiner); add l workup 4 Bring Total to Line A Total 72

73 Table of Risk = B Level of Risk Presenting Problem Diagnostic Proc. Ordered Management Opts. Selected Minimal One self-limited or minor problem eg. Cold, insect bite, tinea corporis Lab tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Rest Gargles Elastic bandages Superficial dressings Ultrasound KOH prep 73

74 Level of Risk Presenting Problem Diagnostic Proc. Ordered Management Opts. Selected Low Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated illness or injury Physiologic test not under stress Non-cardiovascular imaging studies with contrast Superficial needle biopsies Clinical lab test requiring arterial puncture Over the counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy Skin biopsies IV fluids w/o additives 74

75 Level of Risk Presenting Problem Diagnostic Proc. Ordered Management Opts. Selected Moderate One or more chronic illnesses with mild exacerbation, progression, or side effects of tx Undiagnosed new prob. with uncertain prognosis Acute illness with systemic symptoms Acute complicated injury Physiologic tests under stress Diagnostic endoscopies with no risks Deep needle or incisional bx Cardiovascular imaging studies with no risks Obtain fluid from body cavity Minor surgery with identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed tx of fracture or dislocation without manipulation 75

76 Level of Risk Presenting Problem Diagnostic Proc. Ordered Management Opts. Selected High Acute or chronic illnesses or injuries that may pose a threat to life or bodily function One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment An abrupt change in neurologic status Cardiovascular imaging studies with contrast with risks Cardiac electrophysiological tests Diagnostic endoscopies with risks Discography Elective major surgery with risks Emergency major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to deescalate care b/c of poor prognosis 76

77 Data to be Reviewed = C Amount and/or Complexity of Data Reviewed Points Review and/or order of clinical lab test(s) 1 Review and/or order of test(s) in Radiology section 1 Review and/or order of test(s) in Medicine section 1 Discussion of test results w/ performing physician 1 Decision to obtain old records and/or history from someone other than the patient. Review/summarization of old records and/or obtain history from someone other than pt. and/or discussion of case with another provider Independent visualization of image, tracing, specimen itself (not simply review of report)

78 Final Result for Complexity A Number of diagnoses or treatment options 1 Minimal 2 Limited 3 Multiple 4 Extensive B Highest Risk Minimal Low Moderate High C Amount and complexity of data 1 Minimal or Low 2 Limited 3 Multiple 4 Extensive Type of decision making Straight- Forward Low Complex Moderate Complex High Complex 78

79 Medical Decision Making Documentation Guidelines DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation. For a presenting problem with an established diagnosis the record should reflect whether the problem is: a)improved, well controlled; resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected. 79

80 Contributory Factors Counseling Coordination of care Nature of presenting problem According to CPT, although the first two are of these contributory factors are important E/M services, it is not required that these services be provided at every patient encounter. 80

81 Counseling Counseling is a discussion with a patient and/or family concerning one or more of the following areas: Diagnostic results, impressions, and/or recommended diagnostic studies; Prognosis; Risks and benefits of management (treatment) options; Instructions for management (treatment) and/or follow-up; Importance of compliance with chosen management (treatment) options; Risk factor reduction; and Patient and family education. (CPT, 2016) 81

82 Coordination of Care Coordination of care with other providers or agencies without a patient encounter on that day is reported using the case management codes. 82

83 Documentation of an Encounter Dominated by Counseling or Coordination of Care When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services.(cpt, 2016) 83

84 Documentation of Time DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-toface or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care. The extent of the counseling and/or coordination of care must be documented in the medical record. (CPT, 2016) 84

85 Nature of Presenting Problem A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. (CPT, 2016) 85

86 Nature of Present Problem Minimal: A problem that may not require the presence of the physician or other qualified health care professional, but service is provided under the physician s or other health care professional s supervision. (CPT, 2016) 86

87 Nature of Presenting Problem Self-limited or minor: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance. (CPT, 2016) 87

88 Nature of Presenting Problem Low Severity: A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected. (CPT, 2016) 88

89 Nature of Presenting Problem Moderate Severity: A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increase probability of prolonged functional impairment. (CPT, 2016) 89

90 Nature of Presenting Problem High Severity: A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of sever, prolonged functional impairment. (CPT, 2016) 90

91 Medical Necessity Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. (CMS) 91

92 Putting It All Together!! How to Select the Correct E/M Code 92

93 New Patient or Consult (3 of 3) Element Level I Level II Level III Level IV Level V History Prob. Foc Exp Prob Detailed Comp Comp HPI (1-3) (1-3) (4+) (4+) (4+) ROS None (1) (2-9) (10+) (10+) PFSH None None (1) (all 3) (all 3) Chronic Exam Prob. Foc Exp Prob Detailed Comp Comp (1995) (1) (2-7) (2-7) (8+) (8+) Medical Straight Straight- Low Moderate High Decision Forward Forward Making Code min 20 min 30 min 45 min 60 min 93

94 Established Patient (2 of 3) Element Level I Level II Level III Level IV Level V History Non-MD Prob. Foc Exp Prob Detailed Comp HPI Service (1-3) (1-3) (4+) (4+) ROS None (1) (2-9) (10+) PFSH None None (1) (2 of 3) Chronic 3 3 Exam Non-MD Prob. Foc Exp Prob Detailed Comp Service (1) (2-7) (2-7) (8+) Medical Decision Making Non-MD Service Code min Straight- Forward min Low Moderate High min min min 94

95 Document What You Do. And Code What You Document! 95

96 Resources NGS FAQ: 0frequently%20asked%20questions/!ut/p/a1/xVNNc4IwFPwr9OCRSYCg9BjQAn5Rb R2FixNDtFQIFKKO_fUN1k7tQW2nnSkXsu8tL5tlAyIwAxEn22RFRJJzktY4as4R9jua 5sBeYHkQ4l4bIzx0DRcZYAoiEFVky2ierxNWI5oyUn7Cccf1g- GhwUUhnkDIV1XG4oSSUn7FBeOCs10DnpQPuMjThO4_3gqLN_QgSxF5kdCqAd mwpjv3eugxkhfoviyt4y60lgxjxjzyke4vuq1zrehu1csqlljqjaahyrympeat2rrat RUxzVQXiECVQKQxutSRbi1rdj-wQXhPSqHY0qlQOgXPPBhy8gvFCOwIEZ3drs9ujdcWz8SLmwRSg2ts5s4EDz88IxXBurvA6fOYD6adMaSfZIEiU6 TIOExCXJ1atyfKtL- XRE0NfnbHOS3kOfpwWPrt6a7E78jj2j3Jv0J1H0X_Xhg91r2ZHb1cuAMVnIsEU9qw pc5mj29qxdal67xvdrb7yeu2ieiw49dy8jugxw2i-3ri8zenh8omgylcxp1qet8c0bsedyxq!!/dl5/d5/l2dbisevz0fbis9nqseh/?clearcookie=&savecookie=&regi ON=&LOB=Part%20B 96

97 Resources Education/Medicare-Learning-Network- MLN/MLNEdWebGuide/Downloads/97D ocguidelines.pdf Education/Medicare-Learning-Network- MLN/MLNEdWebGuide/Downloads/95D ocguidelines.pdf 97

98 Resources Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/eval-mgmtserv-guide-ICN pdf nect/3632a905-b fc0-2aa2a84fedb2/1074_0115_em_documentat ion_training_tool.pdf?mod=ajperes&atta chment=true&cache=none&conten TCACHE=NONE&LOB=Part+B&REGION =&clearcookie=&savecookie= 98

99 Resources Guidance/Guidance/Manuals/Downloads/c lm104c12.pdf 99