Medicine



Medicine



The Medicine section has many subsections that encompass a broad range of services. Take a moment to review these subsections in the CPT and then review the Medicine Guidelines. The section contains diagnostic (determining nature of disease) and therapeutic (curative) services that are both invasive (entering the body) and noninvasive (not entering the body).



Immune globulins/immunizations/vaccines (90281-90749)


When coding from this section, you will need to remember this is the one section in the CPT manual that actually has codes for both administration of the drug and the drug product. You would usually assign the drug product code from HCPCS National Level II manual. There are payer-specific rules that still may lead you to a HCPCS National Level II code, but there are drug codes in the medicine section for vaccines and immune globulins.


The codes are categorized as follows:






















Vaccine Administration 90460-90474
Vaccine/Toxoids 90476-90749
Immune Globulins 96365-96368,
Administration 96372-96375,
  96375
Immune Globulins Products 90281-90399

The two types of immunizations are active and passive. Active immunization can be either a toxoid or a vaccine and is administered in anticipation that a patient will come into contact with a disease. Toxoids are the bacteria that cause the disease that have been made nontoxic. When the toxoid is injected, the body’s immune system produces an immune response that builds protection from the disease. A vaccine is the injection of the actual virus in small doses to allow the body’s immune system to produce an immune response. Passive immunization does not cause an immune response; rather, immune globulins (antibodies) are injected to protect the body from a specific disease. Within the Medicine section, the codes for active immunizations are Vaccines/Toxoids (90476-90749), and the codes for passive immunizations are Immune Globulins (90281-90399).


Whenever an immunization or immune globulin is administered, the substance (vaccine/toxoid or immune globulin) is reported along with an administration code (90460-90475 for vaccine/toxoid and 96365-96368, 96372, 96374, 96375 for immune globulins). For example, an immune globulin of diphtheria antitoxin (90296) for a patient over 19 years of age, injected intramuscularly, is reported as follows:













90296 Diphtheria antitoxin (substance)
96372 Therapeutic injection subcutaneously or intramuscularly (injection)
Z51.89/V07.2 Prophylactic immunotherapy (diagnosis code)

The vaccination administration codes (90460-90474) are divided by age and route of administration. Codes 90460/90461 (through 18 years of age) are reported for any method of administration of a vaccine when face-to-face counseling with the patient/family is provided. You assign codes 90471/90472 to report intradermal (ID), percutaneous (PERC), subcutaneous (SQ), or intramuscular (IM) administration for patients when the physician did not counsel the family and for all other patients. Codes 90473/90474 are used to report administration by intranasal or oral methods. It is the number of injections that is reported, not the number of substances being injected. For example, if the patient received a tetanus toxoid, rubella virus, and diphtheria toxoid in three separate injections, the service would be reported as follows:

















Substance (Drug Supply) Administration (Service)
90703 Tetanus toxoid 90471 Administration, tetanus toxoid
90706 Rubella virus 90472 Administration, rubella virus
90719 Diphtheria toxoid 90472 Administration, diphtheria toxoid

If a 6-year-old child receives a combination of tetanus and diphtheria, that were injected in one syringe, and the rubella in another syringe, with physician counseling, the service would be reported as follows:















Substance (Drug Supply) Administration (Service)
90702 Tetanus and diphtheria toxoids
90706 Rubella virus 90461 Administration, rubella virus


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An E/M code is reported with an immunization service only when there is another separate, identifiable evaluation and management service provided and documented in the medical record. Report the E/M service with modifier -25 added to the code to indicate that the service was separate from the immunization service. If the only service provided was the injection, it is not appropriate to report an E/M service because administration of the injection is reported with the administration code (90460-90474). The substance injected is reported with the toxoid, vaccine, or immune globulin code, so it is not correct to report a supply code (e.g., 99070) unless some other supply was provided in conjunction with another separate service in addition to the immunization.


Two vaccinations that are commonly provided are influenza and pneumococcal. Report a code for the substance injected (vaccine) and a code for the administration of the vaccine. The third-party payer may require you to submit CPT codes or CPT with HCPCS National Level II codes for the service. The following identifies the codes that are usually reported for influenza and pneumococcal immunizations.


CPT influenza vaccine codes:










90657 Influenza virus vaccine, trivalent, split virus, when administered to children 6–35 months of age, for intramuscular use
90658 Influenza virus vaccine, trivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use

HCPCS National Level II code used to report the administration of an influenza vaccine to a Medicare patient:







G0008 Administration of influenza virus vaccine

CPT codes used to report the administration of the influenza vaccine:










90471 Intramuscular administration, one vaccine
90472 Intramuscular administration, each additional vaccine

The diagnosis code assigned when the only reason for the encounter is an influenza vaccine (flu shot) is Z23/V04.81, Influenza vaccination. The diagnosis and service codes must correlate (connect).


CPT pneumococcal vaccine code:







90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years and older, for subcutaneous or intramuscular use

HCPCS National Level II code to report the administration of the pneumococcal vaccine to a Medicare patient:







G0009 Administration of pneumococcal vaccine

CPT codes used to report the administration of the pneumococcal vaccine:










90471 Intramuscular administration, one vaccine
90472 Intramuscular administration, each additional vaccine

The diagnosis code assigned when the only reason for the encounter is a pneumococcal vaccine (pneumonia shot) is Z23/V03.82. The diagnosis and service codes must correlate.



Diagnoses coding for vaccinations and immune globulins


Vaccinations are reported with Z23/V codes because there is no sign, symptom, or disease actually present. There is only one code in the ICD-10-CM to report vaccinations (Z23), but there are many ICD-9-CM codes available for this assignment.


ICD-9-CM: In the Index of the ICD-9-CM, locate the term “Vaccination.” The subterms are listed by type of vaccination, such as “measles (alone) V04.2.” When referencing the Tabular for V04.2, you will see that V04 reports a vaccination and inoculation for certain viral diseases. The Excludes note indicates that vaccines against a combination of diseases are reported with V06.0-V06.9 codes. If measles, mumps, and rubella were administered in the same vaccination, V06.4 would be reported.


V03 codes are for vaccination and inoculation against a single bacterial disease, such as cholera (V03.0) or typhoid-paratyphoid alone (V03.1). If both cholera and typhoid-paratyphoid were administered in the same vaccination, V06.0 would be reported. V06.0 is a combination code (more than one condition represented by one code) for other combinations of vaccines.


V05 codes are for vaccination and inoculation against a single disease, such as viral hepatitis (V05.3) or varicella (chickenpox caused by the human herpes virus; V05.4).


If one encounter included vaccination for measles, mumps, rubella, and varicella, report the combination code V06.4 (measles, mumps, and rubella) in addition to the single code V05.4 (varicella).


When an immune globulin is administered because a patient was exposed to a disease, the diagnosis code should be reported with a code from category V01 or V07.2 as indicated.



CASE 2-1   2-1A Chart Note


CASE 2-1


Mary Ann Roberts, a Medicare patient, presents for an influenza vaccination. A HCPCS National Level II administration code is used to report the vaccination of a Medicare patient.




CASE 2-2   2-2A Chart Note


CASE 2-2


Gerald is a Medicare patient. Report the services provided by Dr. Naraquist’s nurse.




CASE 2-3   2-3A Chart Note


CASE 2-3


Use the CPT code for the administration and injection service for this non-Medicare patient. A Z/V code is assigned. There is a combination V code for MMRV. There is only one administration; there are several substances in the one administration.




Hydration, (96360, 96361); and therapeutic, prophylactic, and diagnostic injections and infusions (excludes chemotherapy and other highly complex drug or highly complex biologic agent administration) (96365-96379)


Codes 96360-96379 report the administration of drugs/substances for hydration and injection and infusion services other than chemotherapy. The physician’s work related to these services usually involves the oversight of the treatment plan and staff supervision. When the physician provides a significant, separately identifiable E/M service, report the service with an appropriate E/M code and modifier -25. Sometimes third-party payers will require an E/M service provided on the same day as a hydration, injection, or infusion to have a different diagnosis than the condition for which the hydration, injection, or infusion is being provided, but that is not the case for reporting E/M services with these codes. However, modifier -25 must be added to the E/M code, or the E/M service will be thought to be related to the physician’s service for the hydration, injection, or infusion service.


Bundled into the hydration, injection, and infusion services are local anesthesia, placing the intravenous line, accessing an indwelling access line/catheter/port, flushing at the end of the infusion, and all standard supplies.



Hydration


CPT codes 96360 and 96361 report intravenous hydration infusions that include the pre-packaged fluid and electrolytes (such as normal saline) for intravenous hydration infusion. These codes only include the administration and therefore the substance is always reported separately with a HCPCS National Level II code. If a substance other than pre-packaged fluid or electrolytes is infused, then codes 96360 and 96361 are not reported. Rather, the coder would assign Therapeutic, Prophylactic, and Diagnostic Infusion codes 96365-96371 (Intravenous and subcutaneous infusion), or 96379. The Hydration infusion codes include physician supervision and oversight of the staff providing the direct services. Code 96360 is reported for the first hour of intravenous infusion hydration service, and 96361 is used to report each additional hour. Each additional hour is defined as intervals greater than 30 minutes. Therefore, if a patient had 1 hour and 31 minutes of hydration, you would assign code 96360 for the first hour and 96361 for the additional 31 minutes. If the patient only had 1 hour and 30 minutes of hydration, you would only report 96360 because the additional minutes after the first hour were not greater than 30 minutes.



CASE 2-4   2-4A Chart Note


CASE 2-4


This is a Medicare patient.




Therapeutic, prophylactic, and diagnostic injections and infusions (excludes chemotherapy and other highly complex drug or highly complex biologic agent administration) (96365-96379)


Codes 96365-96379 are used to report the administration of a nonchemotherapy therapeutic, prophylactic, or diagnostic intravenous infusion or injection. Intravenous infusions are reported with 96365-96368 and are divided based on the time and type of infusion. The initial infusion is reported with 96365 (up to 1 hour) once per encounter, unless the protocol requires two different venous access sites, and each additional hour of the same drug/substance (up to 8 hours) with 96366. In order to report code 96366, there must be infusion intervals of greater than 30 minutes (up to 1 hour), beyond the initial 1-hour increment of infusion. Sometimes one infusion is provided followed by another infusion of a different drug/substance (sequential infusions). In this case, the initial infusion is reported first with 96365, and the additional sequential infusion is reported with add-on code 96367 for each separate infusate mix. When a sequential infusion runs for more than 1 hour, the CPT guidelines following code 96366 instruct you to report code 96366 for additional sequential hour(s). There are times when more than one infusion of a different drug/substance is provided at the same time, in which case the initial or sequential infusion is listed first, and then the additional concurrent infusion is listed (96368). Code 96368 can only be reported once per encounter. If multiple drugs are mixed together in the same bag, only one administration code can be reported, but all drugs should be billed separately.


Subcutaneous infusion for therapy is reported with codes 96369-96371. The initial subcutaneous infusion code 96369 reports up to 1 hour of infusion and includes the pump set-up and establishment of the site. Code 96370 is an add-on code that reports each additional hour, and 96371 is also an add-on code that reports an additional pump set-up with establishment of a new subcutaneous site.


Therapeutic, prophylactic, and diagnostic injections are divided based on the administration method. Subcutaneous and intramuscular injections are reported with 96372, along with a code to report the substance injected. For example, if 40 mg of Kenalog is injected subcutaneously, J3301 × 4 is reported for the substance, and 96372 is reported for the administration. You would not assign code 96372 to report subcutaneous or IM chemotherapy administration (see 96401-96402). Injections for allergen immunotherapy are reported with 95115-95117, not with therapeutic, prophylactic, or diagnostic injection codes. Intra-arterial injection is reported with 96373. Intravenous push is reported with 96374 and add-on codes 96375-96376. IV or intravenous push is defined as an infusion lasting 15 minutes or less or an injection in which the nurse is continually present to administer the injection and observe the patient. Code 96375 is used for additional IV pushes of different drugs/substances. Once again, all drugs are to be reported separately using HCPCS National Level II codes or CPT code 99070.



CASE 2-5   2-5A Chart Note


CASE 2-5


Report the injection service for this Medicare patient using an HCPCS National Level II code to report the substance injected and a CPT code to report the intramuscular antibiotic injection.




Psychiatry


A psychiatric diagnostic evaluation is an involved assessment to identify an emotional, developmental, or behavioral diagnosis and development of a treatment plan. The physician conducts an interview with the patient to collect information to establish the diagnosis and develop a treatment plan. The evaluation is reported with 90791 (evaluation) or 90792 (evaluation with medical service).


Psychotherapy is the therapeutic treatment of a psychological disorder or behavior and is reported with codes 90832-90838. The codes are time based (30, 45, or 60 minutes) and subdivided based on if the psychotherapy was provided in addition to another primary procedure. The medical record must identify the time spent providing the psychotherapy service. If the time spent providing the service is not recorded on the medical record, the physician should be queried. If no time can be identified, report the service with an E/M code, not a Psychotherapy code. The psychotherapy service may be provided to a patient and/or the patient’s family member.


Crisis psychotherapy (90839, 90840) provides treatment to a patient experiencing an acute reaction to a more specific event or situation. For example, a drug overdose, attempted suicide, or an episode of severe depression. Crisis psychotherapy focuses on the immediate assessment and treatment of the patient in a crisis and is not intended to treat chronic psychological conditions.


The remainder of the codes in this subsection are for Other Psychotherapy (90845-90853) which describes psychoanalysis and individual, family, multiple-family, or group psychotherapy and Other Psychiatric Services or Procedures (90863-90899) which describes medication management, electroconvulsive therapy, biofeedback, hypnotherapy, evaluation of hospital records, consultation, and other services. Most of these codes are not time based, but several are, such as 90875, individual psychophysiological training.


For neuropsychological and cognitive, psychological, developmental, and neurobehavioral testing, you would use codes 96101-96125.



From the Trenchesimage






CASE 2-6   2-6A Psychological Evaluation


CASE 2-6


Joel Wall is an inpatient for whom Dr. Nelson provided an inpatient psychotherapy service. This is not a consultation.



2-6A  Psychological evaluation


LOCATION: Inpatient, Hospital


PATIENT: Joel Wall


PHYSICIAN: Jerome Nelson, MD


REASON FOR VISIT: Joel Wall is a 50-year-old right-handed gentleman who was seen for 65 minutes of interview and records review, in addition to 1.5 hours of testing, scoring, interpretation, and generation of documentation. He is being assessed primarily in regard to postconcussion syndrome.


HISTORY: The patient was involved in a motor vehicle accident on 04/07 of this year and sustained multiple injuries, including bilateral pulmonary contusions, bilateral pneumothorax, and multiple facial fractures, particularly on the left. He is currently on ventilation. The patient did have an alcohol level of .142 at the time of his admission. He has had some reactive depression. Reportedly, the patient has had several prior concussions and motor vehicle accidents. Previous medical history is also significant for chemical dependency treatment in 2000 and again in 2001. The patient had one prior hospitalization on the psychiatric unit last year with adjustment issues following the suicide of his daughter.


Previous medical history is also significant for rotator cuff repair 3 or 4 years ago. The patient is a chronic smoker at the rate of three packs a day. He has a history of borderline diabetes and hypertension. He has chronic arthritis and a history of peptic ulcer.


CURRENT MEDICATION: Mucomyst, albuterol, ipratropium, bacitracin, bisacodyl, Procrit, heparin, Mycostatin, PCS, morphine, Protonix, and Zosyn.


FAMILY HISTORY: Significant for heart disease in the patient’s father who died at age 52; his mother died at age 65 from cardiovascular accident.


SOCIAL HISTORY: The patient lives in Manytown and is currently a widower. He has no surviving children, is a graduate of a 2-year vocational college in the East, and has completed military service.


INTERVIEW: The patient admits he feels somewhat reactively depressed; however, he states that this is nothing like the depression he had about 2 years ago. The patient states that this depression is primarily attributed to being laid off at his place of employment. He feels he is doing well with it. He does not have suicidal ideation. He states that several years ago he became a devoted Buddhist and that has been supportive for him during difficult times. He states that he could go home and stay with one of his nephews with whom he is close.


BEHAVIOR OBSERVATIONS: On interview, the patient is lying in his bed. He is on the ventilator and so has to communicate primarily by writing, which he does do quite efficiently. I do note, however, that the patient includes some extra letters or missequences his letters at times. When asked about this, the patient attributes it to not having his reading glasses. The patient is able to tell me about his accident, although we asked when it happened and he writes that it occurred “July 4”; and when asked whether he is sure about this, he insists that it is true and that it happened after he had been to the local theater to see an adventure show he had been looking forward to. He insists it was on July 4th. He seems surprised and embarrassed when told that, in fact, it happened in April. The patient states that prior to the accident he was actively employed as a carpenter and, when he had time, worked in the evenings and weekends as a painter.


TESTING: On testing, the patient is found to be alert, motivated, and cooperative. Good rapport was easily established. The patient was confident, relaxed, and focused. Of note is the fact that the patient was wearing wrist restraints, which did interfere slightly with some of the testing. The patient did not appear bothered by this. He displayed no difficulty with the comprehension or retention of test instructions. He was careful and reflective in his approach to testing tasks. Test results are believed to be a valid reflection of his current abilities.


The patient proves to be well oriented today (8/8). He has an excellent fund of personal and current information (6/6). He has excellent performance on a test of foresight and planning (Porteus Maze Test: 121/121). Immediate verbal span of concentration is average at 6 forward and 5 backward (50th percentile). Verbal block-tapping span is better yet at 6 forward and 6 backward (91st percentile).


Copying of simple figures is performed well (14/14), as is matching simple figures (4/4). Immediate memory for simple designs is average (58th percentile). After a delay, however, he is noted to lose one of the designs and invert another one. His recollection of the other two is as it was initially. With recognition cueing, he does well (3/4).


Learning of a 9-word categorized list (California Verbal Learning Test) reveals an identifiable learning curve (4, 6, 8, 9, 9). Introduction of a distractor list results in mild retroactive inhibitions (7/9), but the patient improves his performance with semantic cueing (8/9). After a delay he has retained this information. Semantic cueing is not helpful, but with recognition cueing, he is able to identify correctly all 9 of the 9 list items with no intrusive error.


The patient’s response to the Beck Depression Inventory-II results in a score within the normal or nondepressed range (1/3). The patient relates only that he has less energy than he used to have. He denies feeling of dysphoria or sadness and denies any element of suicidal ideation.


IMPRESSION: Joel Wall was involved in a serious motor vehicle accident and received significant facial and upper-torso trauma; he also suffers from postconcussion syndrome. He has been on a ventilator and has had some reactive depression. Current testing would suggest that the patient is not experiencing significant depression at this time. From a cognitive standpoint, he seems to be doing quite well, and there is really minimal if any evidence of cognitive dysfunction.


I will work with Joel to help him with better understanding of the specific obstacles to his being discharged and any progress he might be making on these. When I spoke to him, he indicated that he had no idea of what the specific issues were and certainly had no sense of a timeline, which was a source of great frustration for him.


The patient also identifies that he has benefited from pastoral care from the local Buddhist monk, and hopefully they will be able to follow up with him on a regular basis to provide support.




Dialysis


Dialysis, cleansing of the blood, can be temporary or permanent, depending on the needs of the patient. End-stage renal disease (ESRD) is a condition from which the patient will not recover without a kidney transplant, so these patients require permanent dialysis support. Non-ESRD is a condition from which the patient may recover and needs dialysis support only temporarily.


The End Stage Renal Disease Services provided in the outpatient setting (90951-90962) are divided initially on the age of the patient and the number of visits in the 30-day period. These codes are used to report the physician portion of the dialysis service. The monthly service codes (90951-90962) cover all physician visits to the hemodialysis laboratory during that month to assess the patient while receiving hemodialysis as well as the establishment of a treatment plan (dialyzing cycle) and management of the patient during the month. Monthly service codes 90963-90966 cover all physician related services for home dialysis (peritoneal dialysis) during that full month of service. If less than a full month of service is provided to an ESRD patient in an outpatient setting, assign a code from code range 90967-90970 to report these per-day services.


Hemodialysis or other dialysis procedures are reported with 90935, 90937, 90945, or 90947 to report inpatient ESRD dialysis and inpatient non-ESRD dialysis. The codes are reported on the day of the dialysis procedure. If the physician provides EM services that are unrelated to dialysis, those services are reported separately by adding modifier -25 to the EM code.


Patients can be trained in self-dialysis, which can be performed at home (peritoneal dialysis). Training is reported with codes 90989 and 90993. Most third-party payers allow only one dialysis training course. If a patient is trained to receive peritoneal dialysis after receiving hemodialysis training or vice versa, documentation would need to be submitted to the third-party payer to support the additional dialysis training.


Hemodialysis is performed at the hospital as either an inpatient or outpatient procedure. The physician services are reported based on the type of dialysis the patient is receiving, the complexity of the service, and the number of visits the physician provides to the patient. As with all patients, dialysis patients must sometimes be admitted to the hospital for other medical problems, such as gallbladder disease, and while in the hospital must continue to receive dialysis treatments. When the physician provides an evaluation of the hemodialysis for an inpatient while the patient is receiving dialysis, you would report 90935 (single visit) or 90937 (multiple visits). The multiple visits are provided during the same dialysis session. Code 90937 requires repeated physician evaluations and may include a significant revision of the dialysis prescription. If a hospitalized patient receiving peritoneal dialysis is seen by the physician, the physician services are reported with 90945 (single visit) and 90947 (multiple visits). Code 90947 requires repeated physician evaluations and may include a significant revision of the dialysis prescription. Modifier -26 is not reported with dialysis codes to indicate the professional component of the service was provided because the code description already describes the physician service to the dialysis patient.



CASE 2-7   2-7A Hemodialysis Progress Report


CASE 2-7


The patient is seen in the dialysis unit, which is an outpatient unit. The facility reports a Z/V code as the primary reason for the encounter followed by the diagnosis(es). The physician reports the ESRD diagnoses for the ESRD management service. The date of this service is the 30th day of services provided to this ESRD patient by Dr. Orbitz. Report the monthly ESRD service code (4+) for this 32-year-old patient for both the physician and the facility.



2-7A  Hemodialysis progress report


LOCATION: Outpatient, Hospital


PATIENT: Maryellen Menez


PHYSICIAN: George Orbitz, MD


This 32-year-old patient is seen, and I examined her hemodialysis chart. The patient appears to be hemodynamically stable and not in any form of respiratory distress or compromise. She is tolerating dialysis without any problems. Predialysis vital signs are noted. Blood pressure is 148/60, heart rate 58, respirations 16, temperature 36.3° C (Celsius), and today she weighs 62.7 kg (kilogram). Normocephalic and atraumatic. Pink palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudate. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. No rhonchi, crackles, or wheezes. S1 (first heart sound) and S2 (second heart sound) are distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No laboratory tests are available today.


HEMODIALYSIS: Today we will dialyze her using her left-sided Perm-A-Cath for a total of 3 hours using an HP-150 dialyzer with a 2.0 potassium bath. Will give her a heparin loading dose of 2000 units and a maintenance dose of 1 mL (milliliter) per hour. Vital signs at present are stable. Blood pressure is 120/70, heart rate in the 70s, and she is tolerating a blood flow rate of 350 mL per minute.


ASSESSMENT/PLAN:



At the end of the dialysis, we will give her a dose of Zemplar.




Case 2-7A Discussion


The physician provided 1 month of service with more than 4 encounters. Codes 90951-90962 are reported only once for each month of physician service and include patient management services and evaluations during that month. This 32-year-old patient was provided services for an entire month, and as such the physician’s service is reported with 90960.





Hypertension and chronic renal failure


The Assessment/Plan section of the report indicates that the chronic renal failure is due to hypertension. When hypertension is present with renal failure (N18.-/585.X), the Guidelines direct the coder to assume a cause-and-effect relationship (the hypertension caused the kidney disease). Reference “hypertension” in the ICD-10-CM/ICD-9-CM Index. The subterms “kidney, with, stage V chronic kidney disease (CKD) or end-stage renal disease (ESRD)” directs the coder to assign (I12.0/403.91) to report the hypertension and renal disease. The instructional note under I12.0/403 in the Tabular states that an additional code is to be assigned to report the stage of chronic kidney disease; therefore, a code from category N18/585 is also assigned for the chronic renal disease.



Related posts:

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  4. Evaluation and management services

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May 17, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Medicine

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