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2016 JLU Health Record Systems 1
ICD-10 for Beginners
Four-Part Series
© 2016 JLU Health Records Systems
www.jluhealth.com 1
© 2016 JLU Health Records Systems
www.jluhealth.com 2
Understanding Common
Diagnostic Areas - Where
Coding Mistakes Occur: Part 2
PRESENTER:
Joan L. Usher, BS, RHIA, COS-C ACE
AHIMA Approved ICD-10-CM Trainer
JLU HEALTH RECORD SYSTEMS
TEL: (781) 829-9632 FAX: (781) 829-9636
www.jluhealth.com
2016 JLU Health Record Systems 2
© 2016 JLU Health Records Systems
www.jluhealth.com 3
Learning Objectives:
Understand common home health
coding areas under ICD-10
Including: Skin & Subcutaneous Tissue/Ulcers
Musculoskeletal System
Wounds
Injuries
Aftercare
Diseases of the Skin
& Subcutaneous
Tissue
L00-L99
Review coding guidelines for
ulcers
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Types of Ulcers
Pressure Ulcers L89.-
Also known as decubitus ulcers or bedsores, are localized injuries to the
skin and/or underlying tissue that usually occur over a bony prominence
as a result of pressure, or pressure in combination with shear and/or
friction.
Non-Pressure Ulcers L97-
Lower-limb ulceration are many different types of ulcers with several causes. The
most prevalent are those due to vascular disease, of which venous is the most
common, accounting for over two-thirds of all types of ulcers. There are also
many other causes for ulceration such as malignancy, infections, and skin, drug-
induced, and autoimmune diseases.
Stasis Ulcers I83- or I87-
Venous ulcers (stasis ulcers, varicose ulcers) are wounds that are thought to
occur due to improper functioning of venous valves, usually of the legs (hence
leg ulcers). They are the major occurrence of chronic wounds, occurring in 70%
to 90% of leg ulcer cases. Venous ulcers develop mostly along the medial distal
leg, and can be very painful.
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Pressure Ulcer Stages
Codes from category L89, Pressure ulcer, are
combination codes that identify the site of the
pressure ulcer as well as the stage of the ulcer
Location
Stage
Assign as many codes from category L89 as
needed to identify all the pressure ulcers the
patient has
L89.513 Pressure ulcer, ankle, right, stage 3
L89.612 Pressure ulcer, heel, right, stage 2
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Ulcer, pressure
- pressure (pressure area) L89.9-
- - ankle L89.5-
- - back L89.1-
- - buttock L89.3-
- - coccyx L89.15-
- - contiguous site of back, buttock, hip L89.4-
- - elbow L89.0-
- - face L89.81-
- - head L89.81-
- - heel L89.6-
- - hip L89.2-
- - sacral region (tailbone) L89.15-
- - specified site NEC L89.89-
- - stage 1 (healing) (pre-ulcer skin changes limited to persistent focal edema)
- - - ankle L89.5-
- - - back L89.1-
- - - buttock L89.3-
- - - coccyx L89.15-
4th character
Location
7
Ulcer Lower Limb (Non-
pressure)
lower limb (atrophic) (chronic) (neurogenic)
(perforating) (pyogenic) (trophic) (tropical) L97.909
- - with
- - - bone necrosis L97.904
- - - exposed fat layer L97.902
- - - muscle necrosis L97.903
- - - skin breakdown only L97.901
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L97 Non-pressure chronic ulcer
of lower limb, not elsewhere
classified
Code first any associated underlying condition, such as:
any associated gangrene (I96)
atherosclerosis of the lower extremities (I70.23-, I70.24-, I70.33-,
I70.34-, I70.43-, I70.44-, I70.53-,I70.54-, I70.63-, I70.64-, I70.73-,
I70.74-)
chronic venous hypertension (I87.31-, I87.33-)
diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621,
E10.622, E11.621, E11.622, E13.621,E13.622)
postphlebitic syndrome (I87.01-, I87.03-)
postthrombotic syndrome (I87.01-, I87.03-)
varicose ulcer (I83.0-, I83.2-)
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Unspecified Codes-
Non Pressure Ulcer
Unspecified Codes
Non-pressure ulcer of
ankle
L97.309 Non-pressure
chronic ulcer of unspecified
ankle with unspecified
severity
Missing laterality
Missing depth
More Specificity
Non-pressure ulcer of left
ankle with fat layer
exposed L97.322
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Non-Pressure Chronic Ulcer,
Ankle
L97.32 Non-pressure chronic ulcer of left ankle
L97.321 Non-pressure chronic ulcer of left ankle limited
to breakdown of skin
L97.322 Non-pressure chronic ulcer of left ankle with
fat layer exposed
L97.323 Non-pressure chronic ulcer of left ankle with
necrosis of muscle
L97.324 Non-pressure chronic ulcer of left ankle with
necrosis of bone
L97.329 Non-pressure chronic ulcer of left ankle with
unspecified severity
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Documentation for BMI, Non-pressure
Ulcers and Pressure Ulcer Stages
For the Body Mass Index (BMI), depth of non-pressure chronic
ulcers and pressure ulcer stage codes, code assignment may be
based on medical record documentation from clinicians who are not
the patient’s provider (i.e., physician or other qualified healthcare
practitioner legally accountable for establishing the patient’s
diagnosis), since this information is typically documented by other
clinicians involved in the care of the patient (e.g., a dietitian often
documents the BMI and nurses often documents the pressure ulcer
stages).
However, the associated diagnosis (such as overweight, obesity, or
pressure ulcer) must be documented by the patient’s provider. If
there is conflicting medical record documentation, either from the
same clinician or different clinicians, the patient’s attending provider
should be queried for clarification
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Stasis Ulcer
Ulcer,
stasis (venous) —see
Varix, leg, with, ulcer
- - without varicose
veins I87.2
Chronic (peripheral)
Venous Insufficiency
Varix, - leg (asymptomatic) I83.90
- - with
- - edema I83.899
- - - inflammation I83.10
- - - - with ulcer —see Varix, leg,
with, ulcer, with inflammation by
site
- - - pain I83.819
- - - specified complication NEC
I83.899
- - - swelling I83.899
- - - ulcer I83.009
- - - - with inflammation I83.209
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Varix
- - - ulcer I83.009
- - - - with inflammation I83.209
- - - - ankle I83.003
- - - - - with inflammation I83.203
- - - - calf I83.002
- - - - - with inflammation I83.202
- - - - foot NEC I83.005
- - - - - with inflammation I83.205
- - - - heel I83.004
- - - - - with inflammation I83.204
- - - - lower leg NEC I83.008
- - - - - with inflammation I83.208
- - - - midfoot I83.004
- - - - - with inflammation I83.204
- - - - thigh I83.001
- - - - - with inflammation I83.201
Use additional code
to identify severity of
ulcer (L97.-)
© 2016 JLU Health Records Systems
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Test Your Knowledge
1. Pressure ulcer left elbow stage 1, sacrum stage 2
2. Bilateral pressure ulcers stage 3 buttocks
3. Diabetic toe right ulcer with necrosis to the bone
4. Stasis ulcer (venous insufficiency) of left calf with
skin breakdown
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Answers
1. Pressure ulcer of left elbow (stage 1) L89.021
Pressure ulcer of sacral region (stage 2) L89.152
2. Pressure ulcer of right buttock (stage 3) L89.313
Pressure ulcer of left buttock (stage 3) L89.323
3. Type 2 diabetes mellitus with foot ulcer E11.621
Non-pressure chronic ulcer of other part of right foot
with necrosis of bone L97.514
4. Venous insufficiency (chronic) (peripheral) I87.2
Non-pressure chronic ulcer of left calf limited to
breakdown of skin L97.221
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Diseases of the
Musculoskeletal
System
M00-M99
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Pathological Fractures
3 Types (all require laterality)
Due to neoplastic disease M84.5- - D
M84.551D Pathological fracture in neoplastic disease, right
femur
Code also underlying neoplasm
Due to Osteoporosis M80.8- -D
M80.021D Osteoporosis with pathological fracture humerus
Age related
Other
Osteoporosis without pathological fracture
Due to specified disease M84.6- -D
Code also underlying condition
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Arthritis
Arthritis NOS M19.90
Osteoarthritis NOS M19.90
Needs site and laterality
Requires 6 characters for laterality
Rheumatoid Arthritis M06.9
Need site & laterality
Requires 6 characters for laterality
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Test Your Knowledge
1. Bilateral OA of hip from hip dysplasia
2. RA
3. RA with polyneuropathy of right elbow
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Answers
1. Bilateral osteoarthritis resulting from hip
dysplasia M16.2
2. Rheumatoid arthritis, unspecified M06.9
3. Rheumatoid polyneuropathy with rheumatoid
arthritis of right elbow M05.521
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Injury Coding
Contained in the Injury, Poisoning and Certain Consequences of External Causes
Fractures, dislocations, superficial and internal injuries, open wounds, and burn S00-T34
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Injuries
When coding injuries, assign separate codes for
each injury unless a combination code is
provided, in which case the combination code is
assigned.
Traumatic injury codes (S00-T14.9) are not to
be used for normal, healing surgical wounds or
to identify complications of surgical wounds
Injuries are grouped by body part first, then type
of injury in the tabular listing
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7th
Character Extensions
Injuries will need 7th character extensions to identify the
encounter
A = initial encounter is used while the patient is receiving
active treatment for the condition
D = subsequent encounter is used for encounters after
the patient has received active treatment of the condition
and is receiving routine care for the condition during the
healing or recovery phase.
S = sequela, is for use for complications or conditions
that arise as a direct result of a condition, such as scar
formation after a burn. The scars are sequelae of the
burn
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Fractures
A Traumatic fracture is due to an accident or injury.
A Pathological fracture occurs because a patient’s bones are
weakened by disease such as osteoporosis or cancer.
Pathological fracture coding is part of the Musculoskeletal chapter.
Each fracture is to be coded separately and sequencing of multiple
fractures should be listed in accordance to severity.
Acute fractures refer to the condition that is the primary reason for
the episode of care. Acute fractures are treated at the hospital as
the initial episode of care.
The initial encounter is for active treatment and subsequent is for
patient’s whose active treatment has completed and is now receiving
routine care during recovery and/or healing.
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Fractures
The subsequent episode for the healing of a traumatic fracture is
coded in post acute care.
Examples of fractures for subsequent care include:
care provided during the healing and recovery phase,
follow-up visits,
medication adjustment.
Official Coding Guidelines state that fractures are coded using the
appropriate 7th character for subsequent care for encounters after
the patient has completed active treatment of the fracture and is
receiving routine care for the fracture during the healing or recovery
phase.
In order to code a fracture, the coder must be able to identify if the
fracture is closed or opened.
A fracture not indicated as open or closed should be coded to closed.
A fracture not indicated as displaced or non-displaced should be coded
to displaced.
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Gustilo Open Fracture Classification
Gustilo type Definition
I Open fracture, clean wound, wound <1 cm in length
II Open fracture, wound > 1 cm in length without extensive soft-tissue damage, flaps,
avulsions
III
Open fracture with extensive soft-tissue laceration, damage, or loss or an open
segmental fracture. This type also includes open fractures caused by farm injuries,
fractures requiring vascular repair, or fractures that have been open for 8 h prior to
treatment
IIIA Type III fracture with adequate periosteal coverage of the fracture bone despite the
extensive soft-tissue laceration or damage
IIIB
Type III fracture with extensive soft-tissue loss and periosteal stripping and bone
damage. Usually associated with massive contamination. Will often need further soft-
tissue coverage procedure (i.e. free or ratational flap)
IIIC Type III fracture associated with an arterial injury requiring repair, irrespective of degree
of soft-tissue injury.
© 2016 JLU Health Records Systems
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Test Your Knowledge
1. Aftercare fracture left femur with fractured
leg, left
2. Aftercare fracture hip, NOS
3. Fracture hip (M1011 Inpatient Code)
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Answers
1. Unspecified fracture of left femur, subsequent
encounter for closed fracture with routine healing
S72.92xD
Unspecified fracture of left lower leg, subsequent
encounter for closed fracture with routine healing
S82.92xD
2. Fracture of unspecified part of neck of unspecified
femur, subsequent encounter for closed fracture with
routine healing S72.009D
3. Fracture of unspecified part of neck of unspecified
femur, initial encounter for closed fracture S72.009A
© 2016 JLU Health Records Systems
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Anatomy of a Wound Code
Characters1-3 Type of injury by body site
Character 4 Specific body part
Character 5 Type of Wound
Character 6 Laterality
Character 7 Encounter
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ICD-10-CM Format
Category Alpha Etiology, Anatomical
Site, Severity
Extension
X X X X X X X
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Wounds, Open
ICD-9
Same code
Laceration
Puncture
Bite (human)
ICD-10
Different 5th character
in the code
Laceration
Puncture wound
Bite
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Infected Open Wounds
Code also any associated wound infection
Example: Right shoulder wound,
subsequent episode S41.001D
Infection MRSA B95.62
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Foreign Body in Open
Wounds
Codes to either laceration with or without foreign
body
Codes to either puncture wound with or without
foreign body
Example: Right shoulder laceration with foreign body,
subsequent episode S41.021D
Example: Right shoulder puncture wound with foreign
body, subsequent episode S41.041D
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Build a Code:
Puncture wound to left foot without
foreign body
ICD-10-CM Format
Category
Alpha
Etiology, Anatomical
Site, Severity
Extension
X X X X X X X
S 9 1
S 9 1 3 S 9 1 3 3 2
S 9 1 3 3 2
D
© 2016 JLU Health Records Systems
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Test Your Knowledge
1. Skin tear to right shin, subsequent
episode
2. Puncture wound to left heel with a foreign
body, splinter, subsequent episode
© 2016 JLU Health Records Systems
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Answers
1. Laceration without foreign body, right
lower leg, subsequent encounter
S81.811D
2. Puncture wound with foreign body, left
foot, subsequent encounter S91.342D
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Cellulitis of Toe with Open
Wound
Code wound
Code cellulitis
L03.03- Cellulitis of toe
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.039 Cellulitis of unspecified
toe
L03.04 Acute lymphangitis of toe
Hangnail with lymphangitis of toe
L03.041 Acute lymphangitis of
right toe
L03.042 Acute lymphangitis of left
toe
L03.049 Acute lymphangitis of
unspecified toe
© 2016 JLU Health Records Systems
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Aftercare
Coding
Z40-Z53
Aftercare codes are a subset of the Z codes
Categories Z40-Z53 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state
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Aftercare Following Surgery
Z48.81- Encounter for surgical aftercare following
surgery on specified body systems.
These codes identify the body system requiring aftercare.
They are for use in conjunction with other aftercare codes
to fully explain the aftercare encounter. The condition
treated should also be coded if still present.
Excludes1:
aftercare for injury- code the injury with 7th character D
aftercare following surgery for neoplasm (Z48.3)
Excludes2:
aftercare following organ transplant (Z48.2-)
orthopedic aftercare (Z47.-)
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Z48.810 Encounter for surgical aftercare following surgery on the sense organs
Z48.811 Encounter for surgical aftercare following surgery on the nervous system
Excludes2: encounter for surgical aftercare following surgery on the sense organs(Z48.810)
Z48.812 Encounter for surgical aftercare following surgery on the circulatory system
Z48.813 Encounter for surgical aftercare following surgery on the respiratory system
Z48.814 Encounter for surgical aftercare following surgery on the teeth or oral cavity
Z48.815 Encounter for surgical aftercare following surgery on the digestive system
Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system
Excludes1: encounter for aftercare following sterilization reversal (Z31.42)
Z48.817 Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue
Aftercare Following Surgery
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Other Aftercare Codes
Z46.6 Fitting & Adjustment of urinary
Device
Z43.1 Encounter for attention to
gastrostomy
Z48.01 Encounter for change or removal
of surgical wound dressing
© 2016 JLU Health Records Systems
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Test Your Knowledge
1. Aftercare following surgery, circulatory
2. Gastrostomy (attention to)
3. Long term use aspirin
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Answers
1. Encounter for surgical aftercare following
surgery on the circulatory system
Z48.812
2. Encounter for attention to gastrostomy
Z43.1
3. Long term (current) use of aspirin Z79.82
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Aftercare
Orthopedic
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Aftercare Joint
Aftercare for Joint replacement Z47.1
Use additional code to identify joint (Z96.6-)
Shoulder, elbow, wrist, hip, knee, ankle,
finger, other (5th character)
Requires laterality (6th character)
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Test Your Knowledge
1. Aftercare for joint replacement right hip
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Answers
1. Aftercare following joint replacement
surgery Z47.1
2. Presence of right artificial hip joint
Z96.641
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Z73.2 Lack of Relaxation & Leisure
Before Day of Coding After Day of Coding
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© 2016 JLU Health Records Systems
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Questions????
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Class Companion:
Rapid Reference Guide
Available for beginners & for quick reference.
Allows for easy look-up of home health codes. Pages are organized how clinicians think and by medical abbreviation. Book includes coding updates for 2016.
Cost is for Webinar participants only is $74 (5% discount) including s/h. Offer valid until September 15, 2016.
To download order blank, go to www.jluhealth.com Use discount code NH.
2016 JLU Health Record Systems 26
Resources
Coding
Coding Guidelines
http://www.cdc.gov/nchs/icd/icd
10cm.htm
CMS Materials
https://www.cms.gov/Medicare/
Coding/ICD10/Downloads/ICD1
0ListservCodingResources.pdf
Rapid Reference Guide © 2016
www.jluhealth.com
OASIS
HHA Final Rule 2016 CMS-1625-F
https://www.cms.gov/Medicare/Medi
care-Fee-for-Service-
Payment/HomeHealthPPS/Home-
Health-Prospective-Payment-
System-Regulations-and-Notices-
Items/CMS-1625-F.html
Home Health Agency Center
https://www.cms.gov/center/provide
r-Type/home-Health-Agency-HHA-
Center.html
OASIS Manual
https://www.cms.gov/Medicare/Qual
ity-Initiatives-Patient-Assessment-
Instruments/OASIS/index.html
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ABOUT THE SPEAKER:
JOAN L. USHER, BS, RHIA, ACE, President,
JLU Health Record Systems, Pembroke, MA
Degree in Health Information Management
Certified OASIS and Coding Specialist over 9
years
AHIMA Approved ICD-10-CM Trainer
Author, Rapid Reference Coding Guide, 2016
edition www.jluhealth.com © 2016
Author, Online ICD Coding Courses in
partnership with Libman Education 2012-2016
http://www.libmaneducation.com/healthcare-
education-training/home-health-coding/
Author, ICD-10 Essentials for Home Care:
Your Guide to Preparation & Implementation
www.hcmarketplace.com © 2011
Author, ICD-10 for Home Health: A Guide to
Medical Necessity and Payment
http://www.beaconhealth.org © 2014
Author/Editor Online E-Learning Coding
Courses: Home Health Diagnostic Coding;
Home Health Reimbursement Methods, Home
Health Documentation & Health Record
Requirements AHIMA www.ahimastore.org
© 2011
Contributing editor, Schraffenberger/Keuhn, Effective Mgmt of Coding Services, AHIMA, © 2009
Editor & Contributing Author, MaHIMA, Medicio- Legal Guide to Health Record Information, © 2004, Contributing Author © 2016
Massachusetts Health Information Management Association (MaHIMA), BOD 2004-2011
President , 2006, under her leadership, MA received 4 national awards from AHIMA in Continuing Education Programs, Support for Accredited HIM Education Programs, Legislative Advocacy and Electronic Communications
Co-Chair ICD-10 Task Force 2013-2015
Professional Achievement Award Recipient, MaHIMA, 2008
American Health Information Management Association (AHIMA) delegate 2002-2006
Taught ICD coding for over 20 years and has educated over 17,000 people nationwide
Home Care Alliance of MA, Board of Director 2012-2017, member QI Committee, Facilitator ICD-10 Group 2013-2016
Hospice & Palliative Care Federation MA, Board of Director 2008-2017
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