The Business of Building S i fServices for

Psychosomatic MedicinePsychosomatic MedicineCh i Whi MD JD FCLMChris White, MD, JD, FCLM

Medical Director Psychiatric Consultation Servicef f &Assistant Professor of Psychiatry & Family Medicine

University of Cincinnati College of Medicine

APM 56th Annual MeetingDisclosure: Chris White, MD, JD, FCLM, , ,

PfizerCompanyEmplo mentEmployment

Management

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Independent Contractor

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Speaking & TeachingBoard, Panelor CommitteeMembership D – Relationship is considered directly relevant to the presentation.

I – Relationship is NOT considered directly relevant to the presentation.

To whom are you listening?

Medical Director100 consults/month2-3 Residents2-3 Medical Students1 LISWTransplant ServiceAbout 1 3 FTEAbout 1.3 FTENot loosing money….

Discussion Overview

Coding ReviewHi t El t– History Element

– Physical Exam Element– MDM ElementMDM Element– Consult Coding Synthesis

Practical Tips– Electronic Charge Capture– Smoking Cessation

Drug & Alcohol Screening– Drug & Alcohol Screening

Scenario

A newly minted family medicine & hi t t i d h i i i it dpsychiatry trained physician is recruited

to take over hospital psychiatric consultation serviceconsultation service….– “You’ll never make any money”

“Aren’t you like the fourth doctor on that service– Aren t you like the fourth doctor on that service in as many years”

– “Good Luck”

Revenue as Fuel

Charges are under your controlRelatively easy to track– Useful to learn all that other business stuff

Bulk of the support for the service– Even with 30% no-pay

Horribly misunderstood– Little or no training during residency– Competing ‘ideas’ offered by peers– Lots of folklore on topic

Disclaimer

Coding World– Driven by documentation– Ruled by non-clinicians

D t k / I t ‘F i ’– Does not make sense / Is not ‘Fair’– Blow it = Fraud

Cli i l W ldClinical World– Driven by patient care / bedside events

H d ff & i t i ti hi lHandoff & primary team communication vehicle– Ruled by Clinicians

Necessary for standard of care– Necessary for standard of care– Blow it = Malpractice

Take Home

Do what is clinically needed in order toproperly diagnose treat and follow ourproperly diagnose, treat, and follow ourpatients but also to correctly documentthese efforts in order to get properlyg p p yreimbursed for the care we are alreadyproviding.M di l it f i i thMedical necessity of a service is theoverarching criterion for payment inaddition to the individual requirements ofaddition to the individual requirements ofa CPT code. The volume ofdocumentation should not be the primaryi fl hi h ifi l l iinfluence upon which a specific level isbilled.

Where it goes wrong….

45 y.o. patient presents c/o insomnia– On history s/he endorses for past month low

energy, depressed mood, diff concentrating, and loss of appetiteloss of appetite

– Physical exam is unremarkable– Dx: Depression and start SSRIDx: Depression and start SSRI

3 ways to bill for that visit– E/M Code using Depression (311)E/M Code using Depression (311)– E/M Code using Insomnia (780.52)– CPT Code for Psychiatry (90804 / 90862)CPT Code for Psychiatry (90804 / 90862)

Literature SearchFamily Medicine Literature– Utilize CPT Psychiatry Codesy y

Generally procedures reimburse more.FP’s are already spending that much time.

– Moore Coding for Depression Without Getting DepressedMoore, Coding for Depression Without Getting Depressed, Family Practice Management (March 2004).

Psychiatry LiteratureUtili E/M C d– Utilize E/M Codes

They are not time based.– Rost, Smith, Matthews et al, The Deliberate Misdiagnosis of

M j D i i P i C 3 A h F M d 319Major Depression in Primary Care, 3 Arch Fam Med 319 (1994).

– Goldberg & Oxman, Billing for the Evaluation and Treatment of Adult Depression by the Primary Care Clinician, 6 p y y ,Primary Care Companion to the Journal of Clinical Psychiatry 21 (2004).

Hypothesis

FP’s use symptoms instead of mental health codes to avoid insurance denialscodes to avoid insurance denialsThis leads to an underestimation of the burden of mental illness in primary careof mental illness in primary care

Methods - Retrospective

SettingF il P ti R id t Cli i– Family Practice Resident Clinic

Physicians– 4 Faculty FPs & 20 FP residents

E t DiEncounter Diagnoses– Only those visits with a single Dx

Fatigue (780.79)Insomnia (780 52)Insomnia (780.52)

Chart Review– Review progress note for H&P and treatment provided

Characterize visit as mental health related or not– Characterize visit as mental health related or notmental health dx or antidepressant as txt

Results – Retrospective

32 unique visits Fatigue as only Dx– 18 Represented mental health visits

Dx listed as “depression”Txt prescribed SSRI, SNRI or counselingN l b k h i l fi diNo lab workup or physical findings

– 1 chart unaccounted for– 18/32 = 56% rate of mental illness

7/16 h t f id t i it7/16 charts from resident visits11/16 charts from attending visits

– Not based on insurance provider7 from Anthem7 from Anthem6 from Medicaid2 from Humana3 from others3 from others

Results – Retrospective

26 unique visits Insomnia as only Dx21 t d t l h lth i it– 21 represented mental health visits

Dx listed as “insomnia sec to depression/anxiety”Txt prescribed SSRI, Benzo, or counselingNo lab workup or physical findingsNo lab workup or physical findings

– 1 chart unaccounted for– 21/26 = 81% rate of mental illness

8/9 from resident visits13/17 from attending visits

– Not based on insurance provider6 from Humana5 from Medicaid5 from Medicaid3 from Anthem1 from Medicare6 from others

Coding 101

Choice of E/M vs CPT Procedure Code– Initial Consultations– Subsequent Visits

P h th– PsychotherapyE/M Codes comprised of 3 elements– History– Physical

M di l D i i M ki (MDM)– Medical Decision Making (MDM)Not the same thing as medical necessity

Code must be linked with diagnosisCode must be linked with diagnosis

History Elements

Chief Complaint– One line, a word or phrase

History of the Present Illness (HPI)– 8 elements (goal of at least 4)

Review of Systems (ROS)– >10 systems recognized (goal of at least 3)

Past, Family, and Social History– Can be newly recorded or updated– Avoid simply stating “noncontributory”

HPI

LocationQualitySeverityDurationTiminggContextModifying FactorsModifying FactorsAssociated signs and symptoms

Example

Patient is a 38 y.o. female brought in fori id l id ti Pt t t h f lsuicidal ideation. Pt states she feels

suicidal and the feeling is constant andoverwhelming She has felt this way foroverwhelming. She has felt this way forseveral months. This feeling is worsewhen she drinks and she often haswhen she drinks and she often hasheadaches / nightmares. She reportsdepression and this appears worse in thep ppevenings when she is alone.

Patient is a 38 y.o. female brought in forsuicidal ideation. Pt states she feels

fsuicidal and the feeling is constant andoverwhelming (quality). She has felt thisway for several months (duration) Thisway for several months (duration). Thisfeeling is worse when she drinks and sheoften has headaches/nightmares (assocoften has headaches/nightmares (assocsx). She reports depression and thisappears worse in the evenings (timing)pp g ( g)when she is alone (context).

Location, Quality, SeverityDuration, Timing, ContextModifying FactorsAssociated signs and symptomsAssociated signs and symptoms

Review of Systems

Record + and/or – responsesDon’t duplicate same system– “no nausea, no emesis”

If unobtainable be sure to include reason– “ROS UTO secondary to coma”

Can do pertinent system and then document “remaining review of systems is negative”Can incorporate MS into billiable note

Past, Family, and Social Hx

Can incorporate MS part into billable noteMust be reviewed/updated on each noteAvoid “noncontributory” type jargon

History SynthesisHistory (3/3)

HPI ROS PFS Hx

<4

0

0

PF

1 EPF

2 9 1/3 D

>= 4

2-9 1/3 D

>= 10 3/3 C>= 10 3/3 C

Tips #1 & #2: ROS & PFS Hx

Tip #1– PFS Hx

– Include at least one element on every note

OROR– Make notation that it was reviewed and unchanged on every

noteWithout this no history higher than PF or EPF

Tip #2ROS– ROS

Include at least 2 systems on every noteWithout this no history higher than PF or EPFWithout this no history higher than PF or EPF

History Practice #1RFC : Mental Status Changes50 y o Egyptian male with 2 day onset mental50 y.o. Egyptian male with 2 day onset mentalstatus changes. Pt is endorsing ‘visions’ ofseeing a prophet. No sleep x 4d. Observed byf il t h i d l f hfamily to have increased volume of speech.Has become extremely aggressive with familyrequiring removal of children for safety. Notedb f i d t b l hi t i tiby friends to be laughing at various times.Was brought to ER and spit on staff whenrestrained. No similar incidents in past.pHx of DVT in past, brother with unknown psychdx, married with 3 childrenNo CP No SOB No HA No N/V/C/DNo CP, No SOB, No HA, No N/V/C/D

History Practice #2

Anxiety76 y.o. WF brought in for suspected AMSafter being found by home health aide

k d d li i i filth dnaked and living in filth coveredapartment. Pt reports 10 year hx ofanxiety feels Klonopin helps without itanxiety, feels Klonopin helps, without itreports difficulty walking, anxiety is sobad it interferes with sleep.bad it interferes with sleep.

Physical Exam1997 Psychiatry Specialty Exam

Constitutional– Vital Signs – 3 of the following 7

1) sitting or standing blood pressure1) sitting or standing blood pressure,2) supine blood pressure, 3) pulse rate and regularity,4) respiration,5) temperature,6) height,7) weight (may be measured and recorded by ancillary staff)

General appearance of patient– General appearance of patient

MusculoskeletalA t f l t th d t– Assessment of muscle strength and tone

– Examination of gait and station

Physical Exam Cont.-P hi t iPsychiatric– Description of speech including : rate; volume; articulation; coherence;

and spontaneity with notation of abnormalities (eg, preservation, paucityof language)D i i f h h i l di f h h f– Description of thought processes including : rate of thought; content ofthoughts (eg, logical vs. illogical, tangential); abstract reasoning; andcomputation

– Description of association (eg, loose, tangential, circumstantial, intact)D i ti f b l h ti th ht i l di h ll i ti– Description of abnormal or psychotic thoughts including : hallucinations;delusions; preoccupation with violence; homicidal or suicidal ideation;and obsessions

– Description of the patient’s judgment (eg, concerning everyday activitiesand occasional situations) and insight (eg concerning psychiatricand occasional situations) and insight (eg, concerning psychiatriccondition)

“Mental Status Exam”– Orientation to time, place and person– Recent and remote memory– Attention span and concentration– Language (eg, naming objects, repeating phrases)– Fund of knowledge (eg awareness of current events past history– Fund of knowledge (eg, awareness of current events, past history,

vocabulary)– Mood and affect (eg, depression, anxiety, agitation, hypomania, liability)

Physical Exam Synthesis

Exam

Bullets (Psych specialty) Level(Psych specialty)

1-5 PF

6-8 EPF

9-14 D

>14 (C/P/M + 1 MSK) C

Physical Exam Example #1

A/B -- Hospital gown, cooperative w/ i t iinterviewS -- Normal rate / toneM/A -- “Good” / EuthymicTP -- Goal DirectedTC -- Denies SI/HIP -- Denies AVHI/J -- Limited

Physical Exam Example #2G WDWN WM i NAD i t t l th ti llGen: WDWN WM in NAD in street clothes, partially cooperative with interview w/ dec eye contact, no tics or tremorsGait: No ataxia, WNLGait: No ataxia, WNLNormal muscle strength and toneDecreased spontaneous speech, dec vol“I might be depressed” congruent w/ moodI might be depressed , congruent w/ moodGoal directed, no FOI, no LOANo persecutory delusions or grandiosity No SI/HINo SI/HINo AVH, No RIS, No TBA x O to person, place, and eventsMissed 2 letters on WORLD “DRLW” 2/3 recallMissed 2 letters on WORLD DRLW , 2/3 recallAble to name pen and watch, repeats phrase w/o diffProverb interpretation “green grass is better”Aware of dx of MDD in past but precontemplation w/r/tAware of dx of MDD in past but precontemplation w/r/t EtOH

Tip #3: Make your form work for you

Compare your current note form against th 1997 P hi t i ltthe 1997 Psychiatry specialty examAsk is it possible to document a

h i thi f ?comprehensive exam on this form?If not redo the form and present to h it l f itt f lhospital forms committee for approval.UC examples……..

Medical Decision Making

Number of diagnoses / management tioptions

– Accurately and comprehensively dx the patientParanoid Schizophrenia chronic with exacerbation– Paranoid Schizophrenia chronic with exacerbation

– Mild MR– Etoh Dep Cont

Suicidal ideation s/p TCA ingestion– Suicidal ideation s/p TCA ingestion

Amount / complexity of data reviewedInclude notation of labs reviewed– Include notation of labs reviewed

Risk of complication / co-morbidityRx meds are moderate risk– Rx meds are moderate risk

MDM SynthesisMedical Management (2/3)

#Dx Data Risk MDM

0-1 0-1 Min SF

2 2 Low LC

3 3 Mod MC

4 4 i C4 4 Hi HC

Tip #4: High risk medsManagement Options: Drug Therapy Requiring Intensive Monitoring for Toxicity

– The Table of Risk lists drug therapy requiring intensive monitoring fortoxicity as a high risk management option.

– For drugs with a well-defined clinical response and a high therapeutic index(i e low toxicity) intensive therapeutic drug monitoring is not necessary(i.e., low toxicity), intensive therapeutic drug monitoring is not necessary.For acute or short-term drug therapy there is no advantage to monitoringdrug levels. For treatment of chronic disorders, such as antihypertensivetherapy, if the desired response can be readily assessed by a noninvasivetechnique, such as blood pressure monitoring, serial drug level monitoringis not medically necessaryis not medically necessary.

– Administration of cytotoxic chemotherapy is always considered high riskunder management options when monitoring of blood cell counts is used asa surrogate for toxicity.g y

– Drugs that have a narrow therapeutic window and a low therapeutic indexmay exhibit toxicity at concentrations close to the upper limit of thetherapeutic range and may require intensive clinical monitoring. The tablebelow lists examples of drugs that may need to have drug levels monitoredbelow lists examples of drugs that may need to have drug levels monitoredfor toxicity. This is not an all exclusive list. On medical review, to considertherapy with one of these drugs as a high risk management option, wewould expect to see documentation in the medical record of drug levelsobtained at appropriate intervals.

Drug Category Drugs in that Category Treatment Use

Cardiac drugs Digoxin, digitoxin, quinidine, procainamide, amiodarone Congestive heart failure, angina, arrhythmias y

Antibiotics Aminoglycosides (gentamicin, tobramycin, amikacin) Vancomycin, Chloramphenicol

Infections with bacteria that are resistant to less toxic antibiotics

Antiepileptics Phenobarbital, phenytoin, valproic acid, carbamazepine, ethosuximide, sometimes gabapentin, lamotrigine

Epilepsy, prevention of seizures, sometimes to stabilize moods

Bronchodilators Theophylline, caffeine Asthma, Chronic obstructive pulmonary disorder (COPD), neonatal apnea

Immunosuppressants Cyclosporine, tacrolimus, sirolimus, mycophenolate mofetil, azathioprine

Prevent rejection of transplanted organs, autoimmune disorders

Anti-cancer drugs All cytotoxic agents Multiple malignancies

Psychiatric drugs

Lithium, valproic acid, some antidepressants (imipramine, amitriptyline, nortriptyline, doxepin, desipramine)

Bipolar disorder (manic depression), depression

Protease inhibitors Indinavir, ritonavir, lopinavir, saquinavir, atazanavir, nelfinavir

HIV/AIDS

Putting it all together…..

New ConsultCodes 99251 99252 99253 99254 99255Codes

History PF EPF D C Cy PF EPF D C C

Exam PF EPF D C CExam PF EPF D C C

MDM SF SF LC MC HCMDM SF SF LC MC HC

Time FTF 20 min 40 min 55 min 80 min 110 min

Putting it all together cont.-

Follow-upConsult Codes 99231 99232 99233Consult Codes

History PF EPF Dy PF EPF D

Exam PF EPF DExam PF EPF D

MDM SF/LC MC HCMDM SF/LC MC HC

Time 15 min 25 min 35 minTime 15 min 25 min 35 min

Tip #5: Time Billing

Can use time spent on patient care as j tifi ti f l l f ijustification for level of serviceShould still document progress noteNeed to use language to the effect– “Spent 60 minutes with > 50% of this time

f t f li d di tiface to face counseling and coordinating care for this patient regarding their depression and ongoing alcohol dependence issues”ongoing alcohol dependence issues

Use family centered rounds approach to boost your contact timeboost you co tact t eOften use this approach for MS notes

Coding Conclusion….

Always work with compliance people– Find outliers in your department and provide education

Let your business office prepare reportsLet your business office prepare reports– Drives #1 above and look for bell curves

RVU issue adds a layer of complexityI t i l i ti f l ti t– Incorporates regional variations for malpractice etc

Audit…. Audit….. Audit……

Tip #6: Electronic Charge CaptureObjective

– Clinicians often have difficulty determining the appropriate Current Procedural Terminology Evaluation and Management code to assign to the type and intensity of patient care they provide. The purpose of this study was to develop, implement, and evaluate a handheld charge capture program for use by providers in the long-term care setting.

D iDesign– Using a pre–post study design, we compared the coding accuracy and user satisfaction of an

established paper process with a handheld charge capture program created for this study by means of: (1) preimplementation and postimplementation assessment of coding accuracy, and (2) preimplementation and postimplementation clinician survey.

SettingSetting– We studied an academic division of geriatric medicine.

Participants– Participants consisted of six clinicians who currently spend at least 50% of their clinical time

practicing in the long-term care setting.InterventionIntervention

– A handheld charge capture program to replace the current paper-based charge capture process was reviewed.

Results– Overall coding accuracy improved by approximately 20% when the handheld program was used

instead of a paper coding process. The majority of clinicians found that the handheld program as more idel a ailable efficient easier to se and enco raged the participants to doc mentwas more widely available, efficient, easier to use, and encouraged the participants to document

more completely and accurately in the patient's medical record.Conclusion

– A handheld billing and coding program used by clinicians who provide care for long-term care residents is not only feasible, but leads to an improvement in coding accuracy when compared with a paper process. In addition, clinician satisfaction toward the billing and coding processes i d ith th f th h dh ld

p p p g g pimproved with the use of the handheld program.

Handler, Journal of the American Medical Directors Association, Volume 5, Issue 5, September-October 2004, Pages 337-341

Tip #6: cont.---BACKGROUND T h l d ti t i t ti t d h i iBACKGROUND: Technology advances continue to impact patient care and physicianworkflow. To enable more efficient performance of billing activities, a point-of-care (POC)handheld computer technology replaced a paper-based system on an acute painmanagement service.

METHODS: Using a handheld personal digital assistant (PDA) and software fromMETHODS: Using a handheld personal digital assistant (PDA) and software fromMDeverywhere (MDe, MDeverywhere, Long Island, NY), we performed a 1-yrprospective observational study of an anesthesiology acute pain management servicebillings and collections. Seventeen anesthesiologists providing billable acute painservices were trained and entered their charges on a PDA. Twelve months of data, justbefore electronic implementation (pre-elec), were compared to a 12-m period afteri l t ti ( t l )implementation (post-elec).

RESULTS: The total charges were 4883 for 890 patients pre-elec and 5368 for 1128patients post-elec. With adoption of handheld billing, the charge lag days decreased from29.3 to 7.0 (P 0.001). The days in accounts receivable trended downward from 59.9 to51 1 (P 0 031) The average number of charge lag days decreased significantly with51.1 (P 0.031). The average number of charge lag days decreased significantly withmonth (P 0.0002). The net collection rate increased from 37.4% pre-elec to 40.3% post-elec (P 0.001). The return on investment was 1.18 fold (118%).

CONCLUSIONS: Implementation of POC electronic billing using PDAs to replace apaper based billing system improved the collection rate and decreased the number ofpaper-based billing system improved the collection rate and decreased the number ofcharge lag days with a positive return on investment. The handheld PDA billing systemprovided POC support for physicians during their daily clinical (e.g., patient locations,rounding lists) and billing activities, improving workflow.

Fahy, B.G. 2009, Anesthesia and Analgesia, 108 (2), pp. 583-587

Electronic Charge Entry

Competing productsSome link to hospital for patient dataAllows for bedside charge entry without human factorImproves accuracyFosters comprehensive charge entryAllows for self generation of data reportsg p

Charge Capture Example

Eliminates billing staffFast copy feature for subsequent visitsAllows for handoffs between staffReduces transcription errorsEasier to do than index card approach

Charge Capture Example

Require initial capital expenditurecapital expenditure for equipmentSome oppositionSome opposition from docs who “have always done it thi ”it this way”Allow for expense of trainingtrainingFollow through on billing officebilling office reduction

Tip #7: Smoking Cessation Coding

Face-to-face patient contact of either the intermediate (>3 min and < 10 min) or intensiveintermediate (>3 min and < 10 min) or intensive (>10 min) type performed either by or “incident to” the services of a qualified practitioner for q pthe purpose of counseling the beneficiary to quit smoking or tobacco use.T ti li tt t ( t 8Two cessation counseling attempts (or up to 8 cessation counseling sessions) are allowed every 12 months.yDuring a 12-month period, the practitioner and the beneficiary would have the flexibility to

h b t i t di t i t ichoose between intermediate or intensive cessation strategies for each session.

Tip #7: Smoking Cessation meets CPTCPT codes– 99406 Smoking and tobacco-use cessation counseling g g

visit; intermediate, greater than 3 minutes up to 10 minutes ($12)

– 99407 Smoking and tobacco-use cessation visit;99407 Smoking and tobacco use cessation visit; intensive, greater than 10 minutes ($24)

These codes became effective January 1, 2008Medically necessary E/M also reported w/ modifier 25.

ICD-9-CMCodes should reflect:– Codes should reflect:

The condition the patient has that is adversely affected by tobacco use, orThe condition the patient is being treated for with a therapeuticThe condition the patient is being treated for with a therapeutic agent whose metabolism is affected by tobacco use.

Cost-effectiveness of Smoking Cessation InterventionCessation Intervention

JAMA 1997;278:1759–1766

The 5 A’s

1. Ask about tobacco use1. Ask about tobacco use

2. Advise to quit2. Advise to quit

3 Assess willingness to make a quit attempt3. Assess willingness to make a quit attempt

4 Assist in quit attempt4. Assist in quit attempt

5 Arrange follow up5. Arrange follow-up

Documentation

Documentation in the medical record h ld i l dshould include:

– • The patient's tobacco use;Th ti t' diti d l ff t d b– • The patient's conditions adversely affected by

tobacco use or the therapeutic agent affected by tobacco use;tobacco use;

– • The amount of time spent on tobacco cessation counseling and the context in which it was provided.

Tip #8: Drug & Alcohol SBI

New codes approved by AMA 99408– 99408

Alcohol and/or substance use structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

– 99409 greater than 30 minutes

CMS ScheduleCMS Schedule– RUC recommended values

99408 ~$3099409 ~$60

Can be billed as a separate or added serviceM j h lth l ti i t iMajor health plans anticipate paying

What is SBI: Ask, Inform, Motivate

ASK:– On admission for new patients and at least once

ll f i ti ti t k t li iannually for existing patients, ask two preliminaryscreening questions:

When was the last time you had more than 4 drinks in a day?Do you use marijuana, cocaine, or other drugs?

– If “No” to both questions, simply continue withq , p ynecessary medical care and use the appropriate E&Mcode.

– If “Yes,” conduct a more in-depth screening (AUDITand/or DAST recommended).

What is SBI: Inform

INFORMU th lt f i d th– Use the results of screening and any otherinformation (GGT, BAC, etc) in the patient’smedical record to conduct a brief intervention.medical record to conduct a brief intervention.

– A qualified health care professional presents theq p presults of the screening to the patient,comparing the patient’s substance use tohealthy standards of use and providinghealthy standards of use and providinginformation about the impact that current usepatterns could have on the patient’s health andp pwell-being.

What is SBI: Motivate

MOTIVATE

– A qualified health care professional leads adiscussion that focuses on the impact of thediscussion that focuses on the impact of thepatient’s substance use and possible ways thatthe patient might change behavior. Discussp g gambivalence and reasons for change. Generateplans and commit to plans to change behavior.Schedule check up on change plan or if patientSchedule check-up on change plan or if patientis referred to a specialist for more intensiveintervention. Document screening and briefintervention is entered into the patient’s record.

Documentation

You must document the following:– • The patient's alcohol or other substance use;– • The patient's conditions adversely affected by

alcohol or substance abusealcohol or substance abuse – • The amount of time spent on counseling and

the context in which it was provided.the context in which it was provided.Using validated screening instruments– DASTDAST– AUDIT

Questions?????