All right. Thank you, Kathy. And we are going to talk about diagnosis coding. So we're going to go through the ICD-10 updates. We're actually going to talk a little bit more about guidelines and appropriate use for diagnosis codes since Kathy went over the new diagnosis codes in the first talk today. And then we're going to end it with just some risk adjustment updates as well. All right. So again, we're going to talk about briefly just talk about the new codes pertaining to GI, but again, Kathy went over those. We're going to talk a little bit about the overview of diagnosis guidelines, medical necessity issues, personal history, you know, when to code for personal history versus a current condition, and then importance of Z codes, factors influencing health status, and then risk adjustment as well. So as you guys know, the new ICD-10 codes were updated October 1st of this year. So they're in effect, have been in effect for over a month now. So just make sure that these are loaded into your systems. And not only that, the providers know they're out there to choose. I think that's the big thing. We can get diagnosis codes all we want, but if we don't tell our providers they're in there, how do they know to search for them or add them to their list of favorites, things like that. So again, FAP, there's some bacterial overgrowth codes. I'm going to just quickly go through the short bowel syndrome, intestinal failure, the congenital malformation diagnosis codes, that foreign body sensation in throat and other site, and then your family histories that Kathy went over, and then the noncompliant diagnosis codes. So again, you have the list, you have them twice. And just again, make sure that they're loaded and they're in there for you. All right, so let's talk a little bit about guidelines for diagnosis codes. So I think the thing that frustrates providers is number one, you got to click and click and click and click until you can find a diagnosis code. But another thing that is frustrating too, is that when your providers, whether they are, or if you're a provider listening in, whether you're in the office or the hospital setting, you're searching on your app on your phone or your EMR in the office, whatever, you don't get the prompts that say, this cannot be a primary diagnosis, or you can't report this diagnosis with that diagnosis, or this has to be a secondary. You don't get any of those prompts. And so when you don't have a coder or some edit in place within your practice management system, those claims go out and guess what happens? They get denied. They get denied because of what? Because apparently, technically, we didn't code the right way, or we didn't go by the guidelines, but we don't know those guidelines. So it's kind of best practice, I think, to just put the main, get the main guidelines in place, make sure our providers are aware of them, and then again, have someone internal stopping those claims before they go out to that payer, so we don't get that denial back. So what qualifies for a diagnosis reporting? So it must be documented in the medical record and meet the criteria for reporting. So we talk about the meat of the note. We always use that acronym, monitor, evaluate, assess, address, and treat. So if you've addressed it, you've evaluated it, you've addressed it, you're treating it, that is a diagnosis code that you should report. And I talked a little bit about that in the E&M guidelines as well. Do not code conditions that are previously treated and no longer exist. However, you can still report personal history diagnosis codes if they're impacting your current care plan or influences your treatment. So, you know, if you have a patient that has undergone radiation from a prior cancer, and now they have radiation proctitis, that's probably something you want to report. But if it's a condition that they had five years ago and you're not making any mention of it, we really don't need to be reporting those. For outpatient cases, conditions documented as ruled out, suspected, probable, questionable, or any other term of uncertainty should not be coded. So I know I made a comment when I was talking about decision making. I made a comment about putting in your differentials. And you still definitely want to do that. It's just we are not going to report that as a patient confirmed diagnosis unless what? You go, you do testing, you actually confirm that diagnosis, and from that point forward, you can definitely label that patient with that condition. We always talk about we don't want to label patients with something they don't have. As many of you are well aware, if you've got a patient that gets labeled with a chronic condition, for example, what I'm going to talk about at the end of this presentation, risk adjustment, it's a risk adjusted diagnosis, things like that. And it comes back as, well, oh, the patient didn't have it, we were trying to rule it out. So we want to be careful with assigning diagnosis codes. We also have what they refer to as NEC, not elsewhere classifiable, NOS, not otherwise specified, or unspecified. And those are, I kind of call these diagnosis codes, it's especially the other specified, is we're telling you what it is, but there is no specific ICD-10 code to assign that specific diagnosis, but we want to report it as a condition. All right, unspecified, payers don't like unspecified, it's when information in the medical record is insufficient to assign a more specific code. All right, so when you can assign a other specified versus unspecified, I would do that. For example, I'll give you an example of gastric erythema, okay, so you do an upper endoscopy, you see gastric erythema, you do a biopsy to check for gastritis, H. pylori, things like that. Let's say the biopsy comes back as completely normal, okay, nothing was found. Well, we still have to justify that, what we call funny looking area. So in that case, we justify that biopsy in that funny looking area that we took a biopsy for, in that case, I'm going to assign a diagnosis that says other specified disorders of the stomach and duodenum, because again, I saw something there, but it just didn't resort to a more specific diagnosis. Unspecified is pretty well, you know, anemia unspecified is one of them where you know what, you just don't know, you don't know yet if it's iron deficiency, I've got to do more further workup. The unspecified codes that we want to avoid are like unspecified abdominal pain, okay, we are GI providers, we should know the location, okay, so there are things that we definitely need to avoid for unspecific, but at some point and sometimes we do have, that's our only option. Another guideline is kind of cause and effect type diagnosis codes where one diagnosis could support two different conditions or there's prompts that say use additional code, things like that. When we're talking about like a diagnosis, for example, if you find an ulcer that's bleeding, okay, we have a diagnosis code that says gastric ulcer with bleeding, so we're not going to then assign bleeding as an additional diagnosis, that's going to get thrown out by the payer and say, hey, you can't report these two together. We also have conditions that are integral part of a disease process, all right, so they, you know, ICD-10 states signs and symptoms that are routinely associated with a disease process should not be listed as additional codes unless otherwise instructed by the classification. Signs and symptoms can be reported when a relative related definitive diagnosis has not been established by the provider. So what this means is if I've got a patient that comes in with ulcerative colitis, let's say, and they're having their occasional normal, typical normal symptoms for them, okay, I'm not going to carve those additional symptoms out of that colitis diagnosis. I will do it though if you've got a patient that comes into clinic, now they're having profuse diarrhea, not their norm, and now you're running tests for C. diff and stool studies and things like that. Now I am going to report that as an additional diagnosis because we're saying that, hey, it's not just part of this disease process, we're checking if it's something to make sure it's not anything else. Manifestation etiology, so we have prompts in ICD-10 coding that says either code first or use additional code. All right, so when we have those prompts, we need to identify those underlying conditions if hopefully if the provider is that specific enough. So it says wherever such a combination exists, there is a use additional code note at the etiology and a code first at the manifestation. So basically what this means is you can't, typically in this scenario, you can't leave that diagnosis code alone on the claim, you've got to report it with something else. And some of those, the actual, if you look at any diagnosis code that you come up, you come in contact with, and it says in diseases classified elsewhere, that right there should alert you that this is not a primary diagnosis, okay? It means, you know, the liver condition should be primary, et cetera. So here's a couple of examples of the etiology manifestation where you have to have another diagnosis. Patient presents to the office to discuss test results. Her endoscopy pathology was positive for H. pylori chronic gastritis. Okay, I can't just bill out H. pylori by itself. I'm going to get a denial saying this is not a primary diagnosis or has to be reported with something else. And so K2950 for the chronic gastritis has to go primary to that. So again, if you look at the description there, it says as the cause of a disease classified elsewhere, that's the prompt saying, uh-oh, I have to have someone in front, something in front of it. Here's another one. Secondary varices cannot be assigned primary, all right? So if you treat a patient for esophageal varices from a known liver condition, you've got to put the liver condition primary. So patient has alcohol cirrhosis of the liver with esophageal varices here for EGD with endoscopic banding of varices. So that's K7030 primary and then secondary varices without bleeding secondary. We also have what we call combination codes. It basically is one single code is used to classify multiple conditions. That's what it is. All right, so we've got several in GI. Here are a few of our more popular ones or more common ones. Patient seen in follow-up in the office for ulcerative pancolitis currently having problems with rectal bleeding. Okay, so I'm going to assign ulcerative colitis with rectal bleeding. One diagnosis code. Guys, I see this one when I do reviews, I see this one not assigned correctly. What happens is I typically will see, you know, the provider talk about the rectal bleeding in the HPI and then in the assessment and plan, they may mention it as well, but they code ulcerative pancolitis without complications and then rectal bleeding as a secondary diagnosis. Rectal bleeding should not be carved out of that description because it's included. Okay, so you're only reporting the one single code. Same with ascites, okay, in our liver patients. So if you've got an alcohol cirrhotic patient that also has ascites, one diagnosis code. That's all you use and it's alcohol cirrhosis of the liver with ascites. IBS is the same thing. So you've got IBS-C, IBS-D, mixed IBS, and then unspecified. So you're not going to want to assign unspecified IBS and then diarrhea as a secondary diagnosis. It's all one code, IBS with diarrhea, K58.0. We also have excludes one and excludes two guidelines. We're going to talk about excludes one because that's the more important one. Basically what this means is you cannot report these two diagnosis codes together, okay. It's an ICD-10 rule and payers follow it. And again, the frustration that we have with this is when your doctors or if you're a provider listening in and you're out assigning diagnosis codes in the office and you're assigning diagnosis codes in the hospital, you don't know what can and can't be billed together. And if nobody else is doing a double check on that or we don't have an in-house scrubber that scrubs that before the claim goes out, those claims are going to come back denied because they're following guidelines. So here's an example of one of them. Patient admitted with GI bleed, found to have a bleeding ulcer, bleeding duodenal ulcer treated with endoscopic control of bleed. And I kind of talked about this before. You're going to assign K26.4, but because that diagnosis code includes hemorrhage with hemorrhage, you're not going to then assign K92.2. And the reason I see this one as a big issue is because I'm going to give you an example, hospital, okay. You're rounding on a hospital patient. You do the initial consult. The initial consult, the patient has GI bleed. We don't know why yet, but that's what we're consulted for. So guess what? You assign a diagnosis of K92.2 for GI bleed. When you scope them the next day, you find a bleeding ulcer. So now you still have that K92.2 sitting there. And now you're assigning K26.4. Again, you cannot build those codes together, but you would actually have to take off that K92.2 if you don't have someone looking and scrubbing your claims before they go out, or that will go out and denied or come back denied, I should say. Here's another one. This is a big one on upper endoscopies, okay. As an upper endoscopy for heartburn and dyspepsia. And I see that a lot, which it's common, common issue, okay. R12 can only be assigned in that scenario. And here's why. It's not, it doesn't bump up. So, so it's an excludes one because heartburn and dyspepsia kind of go hand in hand. But the problem is, is the diagnosis for dyspepsia for ICD-10 is also epigastric pain, okay. To me, this is kind of part of it that doesn't make a lot of sense to me. I think these diagnosis should be separate. But what if you have a patient and the indication is heartburn and epigastric pain? Well, guess what? You can only code one of those because it's going to kick back as an exclusion. Makes no sense, but we've got to be aware of it. And then Kathy mentioned this. This was probably our second to last slide on the screening versus diagnostic. Patient presents for open access screening colonoscopy and incidental diarrhea. Further clarification is needed by the provider to determine if this should be diagnostic prior to submitting. So, when I look up Z1211 in the ICD-10 book, there's an excludes one note right below it that says encounter for diagnostic exam code, sign, or symptom. So, again, oftentimes when we try to submit a claim with screening and diarrhea on the same claim, that could potentially kick that claim back to you as a denial, okay. So, you got to make the determination, one or the other. So, here's your list of the most common ones, all right. So, I highly recommend you take these slides, maybe make a list, internal list, and put them up in clinic, put them up somewhere where your providers kind of see that you can't build this with this. So, the heartburn with the epigastric pain slash dyspepsia. We talked about the ascites. Change in bowel habits, that's another one, all right. So, if your lower endoscopy indication says change in bowel habits and diarrhea, well, I am only going to code change in bowel habits. Constipation, diarrhea, which should not be coded out separate. Another one is other fecal abnormalities. So, blood in the stool, like an occult blood, like a test. So, the stool test is positive, that's R19.5. Melanin cannot be billed with that. One's a test, one's a symptom. Same rectal bleeding cannot be billed with GI bleed or melanin. So, it's one or the other, and this one gets me sometimes, because I will look at a, I will look at a visit note, and the chief complaint will be rectal bleeding, and the assessment of plants is melanin. All right, so I'm like, okay, which one? So, rectal bleeding versus melanin, you got to pick one, it's one or the other. Rectal bleeding, obviously, usually tissue, on the tissue, bright red. Melanin is more of a higher source, darker, more significant. So, I think that's why they exclude one from another. And then, of course, K92.2, we talked about that. Look at all of the diagnosis codes that cannot be billed with it. So, any of your GI diagnosis codes that say, with hemorrhage, you know to drop the K92.2. So, gastritis with hemorrhage, rectal bleeding, AVMs with hemorrhage, diverticular disease with hemorrhage, gastritis, ulcers, all of it. Any of those codes that say, with hemorrhage, you're not going to add that diagnosis code. So, question, true or false? Z codes, which are the factors influencing health status, they're kind of the old V codes back in, before ICD-10. Z codes should never be assigned as a primary diagnosis. True or false? False is correct. Now there are some Z codes that can't be primary, but there are several Z codes that have to be primary, okay? So we're going to talk about some of those Z codes. So you know, I don't see a lot of Z codes which are, again, factors influencing health status. It may not be a condition or a diagnosis, but the status of this certainty, this, you know, whatever the patient's resistance to medication or personal history or encounter for a liver transplant, things like that, impact kind of our encounter that we're dealing with. So kind of didn't talk to you about when, you know, when those do factor in, giving you some clinical examples, but these are, again, factors influencing health status. And I don't see a lot of these diagnosis codes assigned, but they're important. You know, resistance to medications, procedure not carried out because of contraindication, that's a good one for poor PrEP colonoscopies, DNR status, dietary counseling. So if the patient's seeing a dietician or they end up coming in to see your nurse practitioner and we're strictly, literally talking to them about their diet and weight loss and X, Y, Z. Patients that are on oxygen, okay, probably impacts decision-making and where we're going to do the procedure and what type of anesthesia the patient's going to have. So in those instances, we want to include these because they are essentially part of our decision-making. All right, long-term current drug therapy, big one, okay. How many patients are on anticoagulants? How many patients pop ibuprofen daily? How many patients are on immunosuppressant biologics? Okay, that was a new diagnosis code last year. So when those impact what we're doing, we need to pull those in as well. Here's your non-compliant diagnosis codes. We have so many. All right, so we've got non-compliance with dietary regimens, underdosing of medication, age-related issues, and then other medical treatments. So this could be, that would fall into maybe upper and lower endoscopy or whatever, or something like that, that's something that's not specific to medication or their diet, it's other. So again, if you're to the point where your patient's truly, truly, truly non-compliant and it's impacting their treatment or how you are trying to give them good quality of care, we need to rerecord these. There's a diagnosis for personal history of failed moderate sedation, Z92.83. Very, very good diagnosis code to use for patients that are undergoing monitored anesthesia care. They may not have risk factors, they may not be ASA3, but the fact that last time we gave them conscious sedation, you know, they were awake, pulling at stuff, combative, whatever, it's a good diagnosis code to use. So here's a few examples. The first one, patient returns this year a dietitian for nutritional counseling and weight management. She has a history of morbid obesity with a current BMI of 43. She was counseled today on diet modification and given an exercise program. All right, so because this was strictly a counseling, we can assign Z71.3 primary, morbid obesity. And guys, when you are addressing obesity, okay, you've got to report the BMI level. That is an ICD-10 guideline. And 99.99% of the time, it's documented in the vitals, up in the vital area. And again, this is only if you're addressing it. If you just say the patient's obese and you really don't address it, or they have a history of it, it's not necessary. But if you're actually addressing morbid obesity, or you're saying that it impacts decision-making, you definitely want to pull that BMI in there with it. Here's another one. Patient with a history of failed therapy with vancomycin presents for fecal transplant due to recurrent C. diff infection. All right, so we are letting the payer know, hey, patient has recurrent C. diff resistant to vancomycin. And then we might, you know, of course, be able to get approved for that fecal transplant procedure. Here's another one. Patient presents to the office for six-month evaluation of ulcerative pancolitis. She's currently doing well on her current Remicade schedule. We'll order labs today to check for vitamin deficiencies and therapeutic levels. So ulcerative colitis with no complications and then long-term current use of immunosuppressive biologics. Here's another one. Patient presents to clinic for evaluation of breakthrough heartburn symptoms, who has a long history of severe GERD. Upon gathering a history from the patient, she admits that she doesn't take her Nexium as prescribed. She states that she often misses doses due to her financial situation and is unable to pay for her refills. So we've got heartburn, reflux, and intentional underdosing of medication due to financial hardship. Personal history versus a current condition. Okay, so I see this a lot in the clinics, especially, I think I see it more in the clinic than I do anywhere else. I see personal history colon polyps, not coded as a personal history, but more of a current polyp diagnosis. That's one of the probably the most common example that I see with GI. Okay, so if it is a past condition, it needs to be reported as past medical history. So ICD-10 specifically states when a primary malignancy has been previously excised or eradicated from its site and there's no further treatment directed at that site, report code Z85 dot dot dot for personal history malignant neoplasm. So this is what an example of what they're saying is a past history versus a current condition. So patient here for follow-up of GERD, patient also that's a personal history colon cancer that was treated three years ago. Okay, so GERD and then Z85.038 should be assigned. Not a C code for cancer. All right, so make sure that we're assigning those appropriately. All right, another one. This has to do with Z08 and Z09. We've got two of those diagnosis codes that are primary, okay, and I will get to those in just a second. But Z1211, let's talk about Z1211 with family history. ICD-10 specifically says you may report screening primary to family history and honestly family history is sitting in ICD-10 as a secondary diagnosis. So oftentimes payers deny family history in the primary position and Z1211 would be primary to that. But for personal history of polyps, cancer, etc., you're going to look at the Z08 or Z09. So we've got follow-up code Z08 and Z09 are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. So the follow-up code is sequence first followed by the history code. And some of you may actually experience this where you're billing, let's say for example Z86.010, personal history colon polyps. If you get a denial back from the payer that says we don't allow this as a primary, that's what they want primary. They want Z09 primary. So some payers follow this, some do, some don't. So Z08, encounter for follow-up exam after completed treatment for malignant neoplasm. Use additional code to identify personal history malignant neoplasm. And then Z09 is for other than malignant neoplasm. So those Z08, Z09 would be primary to those situations. All right, common ICD-10 questions. What is the correct diagnosis for an AVM found in the ileum? This one is tricky guys, okay. It's actually K55.8, other vascular disorder of the testin. For some reason, unbeknownst to me, ICD-10 created a diagnosis for AVM of the small intestine, or there is no, sorry, there is no code specific to AVM of the small intestine. There's only code specific AVM specific to the stomach and duodenum and the colon, okay. So that one's kind of a tricky one. Number two, can we assign Z86.010, personal history colon polyps, for anyone who has colon polyps or is this code limited to those who require surveillance colonoscopies? That's actually a very good question. If you look at the base description of personal history, okay, of colon polyps Z86.01, the term says personal history of benign neoplasm. So I would only assign this code for those who are found to have a true neoplasm or adenomas that have been confirmed by pathology. So hyperplastic polyps technically don't fall into the Z86.010 category. That's more of a personal history of other digestive disorders diagnosis. Number three, what diagnosis code would you assign when the patient has features of Crohn's or UC and the endoscopy, the endoscopy confirms inflammation and or ulceration, but pathology is still not set on one or the other. Okay, I know you guys have seen this. Like the pathologist will say features of Crohn's versus ulcerative colitis, clinical correlation should be required. All right, so they're saying EGI, you make the call. So until that call is made, we have a diagnosis of indeterminate colitis, K52.3. It's colonic inflammatory bowel disease unclassified. So they have IBD, we just don't know which one it is yet. Number four, I have come across EGD reports that state reflux symptoms under procedure indication. What diagnosis code can I assign? None. There is no diagnosis for reflux symptoms. What could that be? Oh my gosh, heartburn, bloating, gas, pain, anything. You got to be specific, document what the symptoms are. So we can't bill that until we send it back to the provider to amend the report. And we've already talked about this one. See, we're going to beat this one in the ground today. Patient presents for screening colonoscopy, patient's first one. The colonoscopy is normal. However, biopsies were taken throughout the colon for microscopic colitis. What diagnosis code do I assign for the biopsy if pathology is normal? Again, why are you doing it? Medical necessity is not met for taking biopsies of normal tissue during a screening. Query the provider and ask why biopsies were taken. Most likely the patient had symptoms that were not reported on the procedure indications. Remember that for the patient to qualify for screening, they must be asymptomatic without abnormalities. All right, risk adjustment. So for risk adjustment, I know we're kind of going over, but I'm going to quickly go through risk adjustment. Many of these slides are just for you to have. They give you the entire list of diagnosis, okay? So they give you all the diagnosis codes in GI that are risk adjusted for you to have. So I'm not going to go through all those. I'm going to quickly go through what risk adjustment is. It's where CMS reimburses the Medicare Advantage plan based on the health of their patients, okay? So they go by demographics, age, gender, as well as pulling diagnosis codes that you submit on claims. That is how they gather a risk score for a patient, okay? So each year that score is reset. Higher risk scores represent either a greater than average burden of illness, and then low risk is either a healthy population or sometimes a falsely healthier population. So we have incomplete chart documentation or incomplete or inaccurate diagnosis coding. On January 1st, the member's score is reset each year. There's some documentation tips for you to reference. I'm not going to go through every single one of these, but basically document everything you address, the cause and effect relationship, code past medical when it's past medical, but leave it as a current condition when it is a current condition. Like, for example, ulcerative colitis, you're probably never going to assign that as a history of ulcerative colitis. Patient's always going to have it, all right? So be careful with assigning those diagnosis codes. Avoid unspecified. Code to the highest level of specificity. Sign your notes. And here are, and again, I'm going to just quickly scroll through the slides real quick. These are all of our GI-specific risk-adjusted diagnosis codes. There is a score to the right of that code. The higher the score, the higher the burden of illness or complications, issues, things that that potentially could have, all right? So we've got hepatitis, all of your malignancy diagnosis codes, stromal tumors, GIST tumors. I'm going to stop at this slide. E10.43 and E11.43. Guys, make sure when you are seeing patients with gastroparesis, if it is from a diabetic issue, make sure that you assign that E11 or 10 code. That is risk-adjusted. Gastroparesis is not risk-adjusted. Just plain old gastroparesis, not risk-adjusted. Most of our signs, symptoms, abnormalities are not risk-adjusted, okay? It's more of our chronic conditions. So just be aware of that one. All right, malnutrition, morbid obesity, all of your alcohol abuse, use-independent diagnosis codes are all risk-adjusted, okay? So I'll quickly go through those. Varices, esophageal varices, whether it's primary or secondary, all of your ulcers are risk-adjusted. Crohn's, all of them. Ulcerative colitis, all of them. Then we get into some more of the higher, more complicated diagnosis codes, which most of these we may hopefully not see. So infarction of the bowel, chronic necrotizing endocolitis, stage 1, 2, 3, paralytic ileus, gallstone ileus, fecal impaction, ileus megacolon, perforation, things like that. Spontaneous bacterial peritonitis, alcohol cirrhosis, all of your liver conditions basically are risk-adjusted. Hepatic failure, chronic hepatitis, primary biliary cirrhosis, portal hypertension, all of them are risk-adjusted. And then you've got your colostomy, gastrostomy complications. They're the highest ones. In the GI world, the colostomy, enteroscopy, gastrostomy complications are the highest. We got transplant rejection, failure, things like that. But look at these Z codes that are risk-adjusted. How many of you changed G-tubes? Encounter for attention to G-tube, gastrostomy, still one of the highest risk-adjusted diagnosis codes. BMI 40 and above are risk-adjusted. Long-term current use of insulin is risk-adjusted. G-tube status. So you may not even be treating that, but patient has it and you evaluated it, you checked it, make sure it was good to go. Reported Z93.1. And then of course colostomy status as well. All of those are risk-adjusted. Comorbidities and risk factors associated. So we might be seeing the patient for a non-risk-adjusted diagnosis, but their chronic condition impacts decision-making. So we gave you those examples on those endoscopic risks for medical necessity. Here they are. Okay. So hypertensive chronic kidney disease, old MIs, AFib, cardiomyopathy, pulmonary heart disease. Now I'm not going to read all these to you. Chronic kidney disease stage three, four, and five. Here's an example of an inpatient note that just to kind of break down what the risk is. So patient is, so hemopositive stool and a significant decrease in hemoglobin in this 90-year-old female who was admitted with significant current pulmonary issues, including COPD exacerbation and acute congestive heart failure. At this point, I do believe we should proceed with an EGD and possibly even colon, depending upon the hemoglobin and hematocrit. I would like her pulmonary status to stabilize. And at that point we will perform an EGD. Patient is at significant risk for this procedure. Procedure-related complications due to COPD exacerbation, acute CHF, bilateral pleural effusions, hypertension, and the advanced age of 90. So if you broke those down into the diagnosis codes and what is risk-adjusted, our GI diagnosis codes that we were seeing the patient for are not risk-adjusted, but her COPD exacerbation is, her congestive heart failure is, but her pleural effusion and hypertension, not risk-adjusted. Okay. So that's kind of where it kind of shows you the importance of pulling those risk factors in when they do impact your decision-making for the patient. You can find the risk-adjusted diagnosis codes. It's free. You can find it on Google, but I did give you the link to CMS for the latest risk models. All right. Thank you very much. And now I am going to transfer this back to Kathy, I believe, and she is going to talk to you about ancillary services.

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