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A P P E N D I X
https://t.me/med1917
What to Tell a Patient Calling with a Varicose Hemorrhage
F
• Press the bleeding point with a finger.
• Don’t stay sitting or standing. Lie down on your back,
elevate the leg.
• Apply a paraffin dressing, cover with a thick stack of
gauze or folded tissues.
• Roll a bandage over the gauze pad in order to apply a
pressure equivalent to the previous finger pressure, no
more. Do not apply a tourniquet. If you have no
bandage, use elastic suspenders or any garment of
elasticated material.
• If you are breathless or dizzy: call emergency on 911.
• If you are not, ask someone to drive you to the office,
where the vein will be injected with a sclerosing agent
and a new dressing applied.
©
2011 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-0-323-07367-7.00028-5
1
Checklist of Questions for Your Secretary to Ask Before
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Passing You a Patient on the Telephone
Secretary Patient’s Answer
FIRST AND FAMILY NAMES
PHONE NUMBER
ADDRESS
Does the Doctor know you already?
When was the last time you saw him?
If not, who’s sending you to him?
A P P E N D I X
G
Have you seen your GP for this purpose?
Did he treat or advise you?
Who is your GP?
What are you complaining of (pain, swollen leg, other)?
Since when (be precise!)?
Which leg? Both legs?
How old are you?
Can you walk?
Are you short of breath?
Are you living alone?
Are you able to give the list of treatments you are currently taking?
The Doctor will need it.
©
2011 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-0-323-07367-7.00029-7
1
A P P E N D I X
https://t.me/med1917
Coding and Billing Guide for Endovenous Laser Ablation
H
July 2010
This guide appears courtesy of CoolTouch CTEV™. All
Medicare payment rates are current as of the time of
printing.
Endovenous Laser Ablation Therapy
The following are possible coding options when coding and
billing for the CoolTouch CTEV procedure. Other coding
options may apply based on the patient’s diagnosis. Coding
of additional diagnoses and procedure codes, just as for principal diagnosis and procedure coding, is dependent on the
documentation in the patient’s medical record. Medical necessity must be met prior to coverage and payment consideration.
Table 1 ICD-9-CM Diagnosis Codes (used by all providers of care)
ICD-9-CM diagnosis codes are used by all providers of care to describe
the patient’s primary, secondary, etc., diagnosis that prompted treatment.
POSSIBLE ICD-9 PRIMARY DIAGNOSIS CODE(S)
454.0 Varicose veins of lower extremities, with ulcer
454.1 Varicose veins of lower extremities, with inflammation
454.2 Varicose veins of lower extremities, with ulcer and
inflammation
454.8 Varicose veins of the lower extremities, with other
complications
POSSIBLE ICD-9 SECONDARY DIAGNOSIS
459.0 Unspecified hemorrhage
459.81 Unspecified venous (peripheral) insufficiency
729.5 Pain in soft tissues of limb
729.81 Swelling of limb
Modifiers
tion with vein treatment procedures. For information on the
correct use of modifiers consult your current CPT book.
Medical Necessity
Medical necessity must be established prior to any service or
procedure being considered for coverage or payment. The
same thing holds true for the CoolTouch CTEV™ procedure.
Medical necessity must be established in order for the procedure to be ‘covered.’ The endovenous laser procedure is
not considered medically necessary for cosmetic purposes;
however, if there is a medical diagnosis warranting the procedure, and all conservative treatments have been tried and
failed, the coverage potential is higher for the endovenous
laser procedure. Some common situations where a medical
necessity for endovenous laser treatment may be demonstrated include:
• A trial period of conservative management has failed.
Conservative management includes walking,
avoidance of prolonged standing, frequent elevation
of affected leg(s), weight loss, use of compression
stockings, etc.
• Leg ulcerations due to saphenous vein insufficiency and
refractory to conservative management.
• Recurrent bleeding from the saphenous vein or other
varicosities.
• Documented incompetence/reflux with Doppler
evaluation and/or Duplex ultrasonography of the
symptomatic varicosity, and documented vessel size >
2 mm.
• Pain or burning in the affected extremity, resulting in
impaired mobility or inability to perform activities of
daily living.
• Recurrent phlebitis or thrombophlebitis, refractory
dependent edema and/or persistent stasis dermatitis.
Payers develop their own criteria for medical necessity.
Individual payers should be consulted for their guidelines.
Modifiers are an essential element of correct CPT coding.
Included below are some common modifiers used in conjunc-
Table 2
Modifier Description
-50 Bilateral Procedures
-51 Multiple Procedures
-58 Staged or Related Procedure by the Same Physician During
the Postoperative Period
-RT / -LT Right side/Left side
©
2011 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-0-323-07367-7.00030-3
Endovenous Laser Ablation Therapy
Facility coding and payment (hospital
outpatient, ambulatory surgery center)
The following are possible coding options when coding and
billing for the CoolTouch CTEV procedure. Other coding
options may apply based on the patient’s diagnosis.Coding of
additional diagnoses and procedure codes, just as for principal
diagnosis and procedure coding, is dependent on the documentation in the patient’s medical record. Medical necessity
must be established before coverage will be considered by any
payer.
1
Appendix
https://t.me/med1917
H
Table 3
Medicare 2010 Natl Avg Payment Rates*
Code Description
COOLTOUCH CTEV ENDOVENOUS LASER ABLATION PROCEDURE
36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging
guidance and monitoring, percutaneous, laser; first vein treated
36479 Second and subsequent veins treated in a single extremity, each through separate
access sites. (List separately in addition to code for primary procedure.)
Note: This is an add-on code and cannot be used without CPT 36478
EXTREMITY VENOUS STUDIES
93965 Non-invasive physiologic studies of extremity veins, complete bilateral study $108.09 Not payable in the
93970 Duplex scan of extremity veins … complete bilateral study $154.69
93971 Duplex scan of extremity veins … unilateral or limited study $97.06
SCLEROTHERAPY/ECHOSCLEROTHERAPY/ULTRASOUND-GUIDED SCLEROTHERAPY
36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb
Coding and Billing Guide for Endovenous Laser Ablation
36470 Injection of sclerosing solution; single vein $59.10 $35.17
36471 Injection of sclerosing solution; multiple veins, same leg $59.10 $35.17
76942 Ultrasonic guidance for needle placement … imaging supervision & interpretation $00 – packaged $00 - packaged
LIGATION
37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal
37718 Ligation, division, and stripping, short saphenous vein $1,786.68 $903.96
37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral
37735 Ligation and division and complete stripping of long and short saphenous veins with
37760 Ligation of perforator veins, subfascial, radical (Linton type), with or without skin
37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate
37785 Ligation, division, and/or excision of varicose vein cluster(s), one leg $1,786.68 $919.25
PHLEBECTOMY
37765 Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions $1,786.68 $1,063.22
or trunk
interruptions
junction to knee or below
radical excision of ulcer and skin graft and/or interruption of communicating veins of
lower leg, with excision of deep fascia
graft, open
procedure)
Hospital Outpatient Amb Surg Center
$1,786.68 $1,117.30
$1,786.68 $1,117.30
ASC setting
$59.10 $35.17
$1,786.68 $903.96
$3,027.81 $1,473.18
$3,027.81 $1,473.18
$1,786.68 $919.25
$1,786.68 $919.25
Code Description
COOLTOUCH CTEV ENDOVENOUS LASER ABLATION PROCEDURE
36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging
36479 Second and subsequent veins treated in a single extremity, each through separate
EXTREMITY VENOUS STUDIES
93965 Non-invasive physiologic studies of extremity veins, complete bilateral study $120.94 $18.07
93970 Duplex scan of extremity veins … complete bilateral study $244.84 $35.40
93971 Duplex scan of extremity veins … unilateral or limited study $161.50 $23.60
2
ENDOVENOUS LASER ABLATION THERAPY
Physician Payment – Facility and Non Facility Setting
Medicare 2010 Nat’l Avg Phys Payment*
Non-Facility Facility
$1,426.98 $369.84
guidance and monitoring, percutaneous, laser; first vein treated
$403.02 $181.05
access sites. (List separately in addition to code for primary procedure.)
Note: This is an add-on code and cannot be used without CPT 36478.
Table 3
https://t.me/med1917
Medicare 2010 Natl Avg Payment Rates*
Code Description
SCLEROTHERAPY/ECHOSCLEROTHERAPY/ULTRASOUND-GUIDED SCLEROTHERAPY
36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb
or trunk
36470 Injection of sclerosing solution; single vein $139.01 $72.64
36471 Injection of sclerosing solution; multiple veins, same leg $171.83 $102.57
76942 Ultrasonic guidance for needle placement … imaging supervision & interpretation $185.47 $34.66
LIGATION
37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal
interruptions
37718 Ligation, division, and stripping, short saphenous vein $450.22 $450.22
37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral
junction to knee or below
37735 Ligation and division and complete stripping of long and short saphenous veins with
radical excision of ulcer and skin graft and/or interruption of communicating veins of
lower leg, with excision of deep fascia
37760 Ligation of perforator veins, subfascial, radical (Linton type), with or without skin
graft, open
37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate
procedure)
37785 Ligation, division, and/or excision of varicose vein cluster(s), one leg $356.56 $268.80
PHLEBECTOMY
37765 Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions $475.29 $475.29
*All Medicare payment rates are current as of the time of printing.
Hospital Outpatient Amb Surg Center
$00.00 $00.00
$259.95 $259.95
$502.95 $502.95
$655.97 $655.97
$655.60 $655.60
$268.43 $268.43
Endovenous Laser Ablation Therapy – Predetermination and Appeals
Endovenous Laser Ablation Therapy –
Predetermination and Appeals
Once a candidate has been identified for endovenous laser
ablation therapy and an ABN (Medicare)/Waiver of Financial
Liability (private payers) has been signed by the patient (in
case of non payment of benefits), a request for predetermination of benefits should be submitted to the patient’s insurance
company. Note: Medicare does not perform predetermination
or preauthorization – coverage is based on medical necessity
and other established criteria. Predetermination of benefits
may be performed via phone, letter, or fax. Recently, some
payers have started to predetermine benefits ‘on-line’ which
may provide another option.
Note: The –GA modifier should be used when submitting
claims for Medicare beneficiaries if a signed ABN is on file with
the provider.
Why predetermination?
What is precertification?
Precertification is usually required for hospital admissions,
and clarifies in advance the expected length of stay, diagnosis
and proposed treatment.
What is preauthorization?
Preauthorization determines in advance if any procedure
codes require medical review prior to treatment. Many insurance companies require that elective surgeries and procedures,
such as endovenous laser ablation be preauthorized. Medicare
is the exception. Medicare does not preauthorize services.
What is predetermination?
Preauthorization clarifies only if a procedure requires medical
review. Predetermination reviews not only if preauthorization
is required but also reviews the patient’s benefit plan for any
exclusions, specific requirements, etc. The request is based on
policy provisions and allows an explanation of the patient’s
potential benefits. A predetermination of benefits gives you
and your patient a better idea of the patient’s anticipated outof-pocket responsibility.
Appeals
Adequate justification for treatment is required for all appeals.
Supporting documentation can play an important role in
obtaining a positive determination for a denial of services
and/or low payment appeal. Documents that may be useful
in supporting an appeal for endovenous laser treatment
include:
• case history information
• treatment plan and progress notes
• consultation reports and test results
• operative report
• ultrasound reports
• correspondence with beneficiary, carrier, hospital,
laboratory, etc.
• preauthorization approval letter and number
• PCP referral
3
Appendix
https://t.me/med1917
H
Coding and Billing Guide for Endovenous Laser Ablation
• peer-reviewed published articles in support of treatment
efficacy.
Note: In some cases EVLT may be denied as ‘investigational;
unproven’ or in other cases ‘not FDA cleared’. These state-
ments are not true and will need to be appealed. For assistance
with documentation in support of these appeals, please
contact the CoolTouch Reimbursement Line at 800-471-9387,
ext. 310.
Endovenous Laser Ablation Therapy Predetermination and Appeals – Flow Chart
ENDOVENOUS LASER ABLATION THERAPY
PREDETERMINATION AND APPEALS – FLOW CHART
Patient identified for endovenous laser procedure
after conservative attempts have been tried
(medical necessity MUST be established)
Call insurance company to determine if
preauthorization required
Preauth
required
Submit
Preauthorization
request to
patient’s insurance
carrier
Preauth
NOT required
Document name
of person,
department,
phone number,
date and time of
conversation
Authorization
Received?
No
Determine why the request
was denied
Non-coverage
decisions usually
based on lack of medical
necessity or other payer
specific policy provisions
and will be the
basis for appeal
Yes
Note patient’s
file and
maintain all
documentation/
correspondence
with payer
Letter should include:
• Medical necessity
• Alternative treatments tried
• Efficacy of the CoolTouch CTEV
procedure
• Details on why why this procedure is
preferred over other treatments
• FDA clearance notification
Letter mailed and faxed
to Medical Director’s
attention at patient’s
insurance company
Follow up with insurance
carrier within a few days
to inquire about status
of request
Inquire about the payer’s
Appeal Process:
What is the process to be followed?
Where should the appeal be sent?
What additional information would
help support the appeal?
Submit formal appeal
4
Endovenous Laser Ablation Therapy
RE: Patient’s Name:
https://t.me/med1917
Predetermination – sample predetermination letters
ID number / Group#:
Date of Birth:
Predetermination of benefits: Endovenous Laser Ablation (EVLA)
CPT Code: 36478 and 36479
Please consider this letter a request for preauthorization of benefits to treat my
patient, [insert patient name], who suffers from [insert patient ICD-9-CM
diagnosis code and description of code]. It is my clinical judgment that
[Mr. / Ms. insert patient last name] is an ideal candidate for endovenous laser
treatment and prior to scheduling this procedure I am seeking predetermination of benefits
for my patient.
[Mr. / Ms. insert patient name] presented to me with complaints of [insert
detailed patient history with description of patient’s current condition
including diagnosis, lenght of time problem has existed, current/ongoing
complaints, and level of impairment. Describe functional impairments, and how the
patient’s condition has impacted his/her activities of daily life].
Previous interventional treatment efforts include: [indicate procedures, medications,
and/or therapies attempted - use of compression stockings should be noted include outcome of each treatment]. Despite these treatments and therapies,
[Mr. / Ms. insert patient name] has experienced no significant relief from [insert
specific symptoms here].
A problem-focused history and exam was performed as well as an ultrasound duplex
scan of [indicate right lower extremity/left lower extremity/bilateral lower
extremities]. [Mr. / Ms. insert patient last name] [insert all tests performed
here] [is/are] attached and [shows/show] [insert test findings to support
request for treatment]
I am recommending endovenous laser ablation (EVLA), using the FDA-cleared CoolTouch
TM
CTEV
, to shrink the [indicate vein and/or veins to be treated] in [indicate right lower
extremity/left lower extremity/bilateral lower extremities]. This procedure offers [Mr. / Ms. insert
patient last name] a minimally invasive, cost-effective alternative to vein stripping with vastly
improved patient outcomes.
This procedure will be performed in [indicate site of service and name of
facility where the procedure will be performed - physician office, ambulatory
surgery center, outpatient hopital]. Please confirm if there are any restrictions on
performing this procedure in this setting.
Indicate diagnosis
code and proposed
procedure
Endovenous Laser Ablation Therapy
Establish Medical
Necessity! Include
medical history, level
of impairment, etc.
Indicate all prior
treatments tried &
failed; length of time
conservative attempts
tried, etc.
Indicate medical
findings and test
results to support
medical necessity of
procedure
Indicate procedure
details such as site of
service, date (if
scheduled), etc.
If you have further questions regarding this request for preauthorization, please do not hesitate to
contact me at [insert phone number]. I look forward to your timely response as [Mr. / Ms. insert
patient name] is eager to move forward with this treatment.
Sincerely,
Doctor
5
Appendix
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H
Coding and Billing Guide for Endovenous Laser Ablation
Endovenous Laser Ablation Therapy –
Frequently Asked Questions
Q. Some of our patients refuse to wear the compression
stockings due to the level of discomfort. Will that be a
problem in trying to establish medical necessity?
A. Possibly. Most payers are very specific in their criteria for
medical necessity of varicose vein treatments. All payers
seem to require use of compression stockings for varying
time periods. We recommend consulting with individual
payers if there is a clinical reason the patient is unable to
wear compression stockings.
Q. Does the endovenous laser ablation need to be
preauthorized?
A. Usually. Although Medicare does not preauthorize
services, non-Medicare payers may preauthorize, and often
times require it. Preauthorization clarifies benefits and
payment rates in advance, allowing you and your patient to
make informed decisions about their care. The patient’s
individual policy and payer guidelines should be consulted
for appropriate preauthorization and referral requirements.
Unfortunately, many payers no longer provide
preauthorization for outpatient procedures or for services
under a specified dollar amount. Instead, services are
reviewed for medical necessity and coverage when the claim
is received. Accordingly, we strongly recommend that you
have your patient sign a Waiver of Financial Liability in the
event of a non-coverage or partial-coverage decision.
Q. Our claims are occasionally denied based on
‘experimental/investigational’ status. How do we get paid for
those claims?
A. We have found that some payers are denying EVLA as
‘experimental’. This is an incorrect reason for denial and
should be appealed. Denials based on ‘experimental status’
are usually due to a misunderstanding of the procedure.
This can be quickly rectified during the appeal process by
providing a description of the procedure, other published
private payer policies citing coverage for EVLA, 2 or 3 local
Medicare coverage policies; and a current bibliography of
published articles (for a copy of the most current CTEV
related bibliography, visit our website at: http://cooltouch.
com/files/ctev.bibliography.pdf). A good way to avoid
denials from private payers is to request a predetermination
of services, prior to rendering treatment, whenever possible.
For additional questions on appeals, please contact our
Reimbursement Hotline at 800-471-9387, ext. 310.
6
Endovenous Laser Ablation Therapy – Sample Physician Claim Form (CMS-1500)
https://t.me/med1917
ENDOVENOUS LASER ABLATION THERAPY
SAMPLE PHYSICIAN CLAIM FORM (CMS-1500)
MEDICARE MEDICAID CHAMPVA GROUP
1.
(Medicare #) (Medicaid #) (Member ID#) (SSN or ID) (SSN) (ID)(Sponsor’s SSN)
X
2. PATIENT’S NAME (Last Name, FIRST NAME, Middle Initial)
Jones, John J.
5. PATIENT’S ADDRESS (No., Street)
CHAMPUS
3. PATIENT’S BIRTH DATE SEX
6. PATIENT RELATIONSHIP TO INSURED
1234 Any Street
CITY
8. PATIENT STATUSSTATE
Anywhere USA
ZIP CODE TELEPHONE (Include Area Code)
99999 (999) 999-9999
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
b. OTHER INSURED’S DATE OF BIRTH
MM DD YY
c. EMPLOYER’S NAME OR SCHOOL NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
Field 21:
PLEASE READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
and also request payment of government benefits either to myself or to the party who accepts assignment
SEX
M F
10. IS PATIENT’S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
10d. RESERVED FOR LOCAL USE
HEALTH PLAN
MM DD YY
09
19 1931
Self
Spouse Child Other
X
Single
Employed
FECA
BLK LUNG
M F
X
Married Other
X
Full-time
Student
YES NO
X
YES NO
X
YES NO
X
Other 1a. INSURED’S I.D. NUMBER (For Program in Item 1)TRICARE
Part-time
Student
PLACE (State)
Enter
appropriate
ICD-9-CM
1?. ????????????????????G PROGRAM NAME
19. RESERVED FOR LOCAL USE
21. DIAGNOSIS OR NATURE OF ILLNESS
454.2
1.
2.
24. A. DATE(S) OF SERVICE
From
MM DD YY MM DD YY EMG CPT/HCPCS MODIFIER POINTER
I
Field 24B:
I
P
Enter appropriate
code indicating
where service
was provided
B. C. D. PROCEDURES, SERVICE, OR SUPPLIES E.
To
PLACE OF
SERVICE
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
GIVE FIRST DATE MM DD YY
Field 24D Enter
17a.
modifiers where
17b.
appropriate. Note:
Use modifiers to
s 1, 2.
denote which leg
3.
was treated (-RT, ???)
4.
(Explain Unusual Circumstances) DIAGNOSIS
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
7. INSURED’S ADDRESS (no., Street)
CITY STATE
ZIP CODE
NOTE: SAMPLE ONLY -
?.
TELEPHONE (Include Area Code)
PHYSICIAN SHOULD CODE
?.
AND BILL FOR SPECIFIC
SERVICES PROVIDED. THE
?.
CODES LISTED BELOW ARE
?.
EXAMPLES ONLY FOR THE
PURPOSE OF ILLUSTRATION.
?.
YES NO
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or supplier for
services described below.
SIGNEDDATESIGNED
MM DD YY MM DD YY
FROM
Field 23: Enter
preauthorization
number if available
22. MEDICAID RESUBMISSIOM
CODE ORIGINAL
23. PRIOR AUTHORIZATION NUMBER
ZZZYYY1234567
F.
$ CHARGES
If yes, return to and complete items’s a-d
TO
LED TO CURRENT SERVICES
MM DD YY
TO
Field 23G Enter
appropriate
number of units
for each service
provided
G.
DAYS
OR
UNITS
H.
PSDT
Family
Plan
I.
ID.
QUAL.
J.
RENDERING
PROVIDER ID #
Endovenous Laser Ablation Therapy – Sample Physician Claim Form (CMS-1500)
01 01 01 0110 10 11 36478 RT 1
Field 23D: Enter appropriate
codes for applicable services,
procedure and supplies.
Include appropriate
documentation where
25. FEDERAL TAX I.D. NUMBER
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGRESS OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
SIGNED DATE
11 XXXXX
SSN EIN
26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
Enter provider information
including provider number or
other identifying information
Field 23E
Enter diagnosis code(s)
corresponding with
(Fro govt. claims. see back)
YES NO
$$$.$$
$$$.$$
1
Field 23J
Enter appropriate
charges for each
service/supply
$
33. BILLING PROVIDER INFO & PH #
Vein Specialists
999-9999999
a. b.
XXX999
1
1
$
NPI
NPI
NPI
NPI
Field 23J
NPI
Enter Medicare
NPI
Provider ID #
AMOUNT PAYED
and National
Provider ID #
(
(NPI) if
7
Appendix
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H
Coding and Billing Guide for Endovenous Laser Ablation
Endovenous Laser Ablation
Therapy – Note
This information is provided as a guide for coding procedures
and services for the CoolTouch CTEV for endovenous laser
ablation and is intended to assist providers in accurately
obtaining coverage and reimbursement for health care services. It is not intended to increase or maximize reimbursement
by any payer. Providers assume full responsibility for all reimbursement decisions or actions. Procedures done concurrently
should be coded according to the procedures performed.
8
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