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Sanof commits to blood pressure chart high systolic low diastolic buy amlodipine mastercard only perform clinical studies one of 14 companies to heart attack 911 order amlodipine 5mg with amex have both fnancial in countries where it intends to blood pressure chart free printable discount amlodipine 10mg mastercard make the prodand non-fnancial incentives in place to arteria jejunalis order on line amlodipine motiAbove average transparency regarding uct available. It also publicly reports on commitfnancial support and membership of relevant ments, objectives, targets and performance organisations. It publicly discloses its policies for Does not publicly commit to equitable pricing information. Sanof does not commit to fling ted to adapt its production capacity based on approach to payments made to healthcare proits newest products for registration in countries needs, and to help provide vaccines to millions fessionals in countries in scope. Publicly commits to R&D to meet public health Some new products in scope fled for registraSome transparency about stakeholder engageneeds. Sanof has publicly committed to R&D for tion in the majority of priority countries. Its R&D strathas fled 40% of its newest products for regstakeholder groups it engages with on access egy for lowand middle-income countries is istration to date in more than half of the releissues, but does not publicly share its process for informed by an evidence-based public health vant priority countries (disease-specifc subsets selecting who to engage with, nor its policy for rationale based on public health targets. Further, of countries with a particular need for access to ensuring responsible engagement. It does incorit has time-bound strategies for completing R&D relevant products). It also publicly shares some porate local stakeholder perspectives into the projects for diseases in scope and evaluates proregistration information for the minority of its development of access strategies. It demonstrates eviwith ethical marketing and anti-corruption Access provisions in place for 40% (10/25) of dence of having equitable pricing strategies for standards. Unlike most of its peers, Sanof does not disDoes not provide evidence of reporting subclose the status of its products for diseases and standard or falsifed medicines within the reccountries in scope. Sanof has a policy for reporting cases of substandard or falsifed medNo use of non-assert or licensing arrangeicines to relevant authorities. Sanof does not engage in voluntary not require reporting to occur within the time licensing nor has it issued non-assert declaraframe of seven days looked for by the Index. Sanof donated During the period of analysis, beyond existing medicines on the request of relief agencies. Sanof has miasis supplies efornithine (Ornidyl), melarso18 capacity building initiatives that were included prol (Arsobal) and pentamidine (Pentacarinat) for analysis by the Index: i. Companies could submit a maximum of 25 initiatives across all areas for Addresses long-term access by aiming to elimassessment; Sanof submitted 23. Sanof commits to long-term structured donation programmes by aiming to Strong focus on local manufacturing and eliminate the diseases in question. Sanof has iniine (Ornidyl), melarsoprol (Arsobal) and pentiatives which meet inclusion criteria in all fve tamidine (Pentacarinat) donation programme areas of capacity building. Management: Falls 4 places to 12th lacking board-level responsibility for Patents. Compliance: Holds 3rd place, extending ethical standards to third parties, Donations. R&D: Rises 2 places to 6th, with a clear strategy for engaging in R&D to Average Leader meet public health needs and 17 projects targeting priority R&D gaps. Below average performance in both registration and pricing with weak outward-facing commitments. Average performance with initiatives meeting most good practices standards but none meeting all. Eisai sions, including equitable pricing strategies and can improve its process to develop access plans by expanding this process to all projects patent waivers, for projects targeting neglected for diseases in scope and consider the unique requirements needed for each project. This includes developing access plans for projects such as lenvatinib Laboratories and the Broad Institute to continue (Lenvima), an oral medicine which was approved after the period of analysis for the developing projects in collaboration that target treatment of liver cancer. Eisai’s products for epilepsy, peramted to measure impact and share results publicly panel (Fycompa), rufnamide (Inovelon) and zonisamide (Zonegran), have been fled via Access Observatory. Clinical candidates: 28, including eritoran for the treatment of infuenza and Portfolio focus: non-communicable diseases (epilepsy). Access provisions: for 15 projects, most commonly applied through access-oriented partnerships. Its pharmaceutical business has reports sales in 27 countries in scope; one more three areas: prescription pharmaceuticals, conthan in the 2016 Index. The dence of formal processes in place to ensure process considers some R&D projects for disHas a strong access-to-medicine strategy compliance with standards by third parties. In general, Eisai develops of 14 companies that performs strongly with sales targets, but rather on the uptake of patient access plans for R&D projects for neglected regards to its access-to-medicine strategy which screening and treatment. To date, Eisai has project-specifc access on long-term sustainable solutions, that expliccriteria. Eisai performs procedures to segregate duties, so that deciPolicy to ensure post-trial access; commits to strongly in encouraging employees to work sions are checked by another party. It is one of 14 however, demonstrate evidence of a monitorfor ensuring post-trial access to treatments for companies to have both fnancial and non-fnaning system in place to track compliance in the clinical trial participants. However, this policy is cial incentives in place to motivate employees to workplace. Eisai publicly discloses products in all countries where clinical trials for its policy positions on access-related topics. One of 16 companies working on impact measits position on intellectual property). Furthermore, it is part of the Access ments made to healthcare professionals in counDoes not commit publicly to equitable pricAccelerated initiative, which includes a committries in scope. Neither does it publicly commit stakeholder groups it engages with on access to implementing equitable pricing strategies. Eisai has publicly committed to R&D for gies for some products in scope of the Index. Eisai for ensuring responsible engagement — in order rationale by following external targets includhas not fled any of its newest products for regto deal with stakeholders in a responsible way, ing the United Nations Sustainable Development istration to date in more than half of the relewith respect and trust and which includes a no Goals. Further, it has time-bound strategies for vant priority countries (disease-specifc subsets tolerance policy for bribery or corrupt behaviour. However, it pubeases in scope where priorities exist, Eisai is licly shares detailed registration information for Has measures to ensure third-party compliactive in 19 projects; 17 of these target priority a minority of its products. Eisai has initiaOne of fve companies running donation proits products for diseases in scope. All of these strategies apply interand Most of these initiatives are focused on R&D intra-country pricing; these take into account an capacity building and health system strengthenaverage of six and four socioeconomic factors, ing. Globally consistent recall guidelines for counMost initiatives meet most good practice tries in scope but no processes to track prodstandards. Eisai has guidelines for drug recalls that meet all the good practice standards looked for apply to all countries in scope. While most of its initiatives have demonstrate evidence of having processes to good governance structures in place, the standtrack the distribution of products in countries in ard it most commonly falls short on is monitorscope to facilitate rapid and efective recalls. Eisai provides evidence that it systematically confrms Publicly discloses detailed information on suspected cases of substandard or falsifed patent statuses. This will be periodically updated and imum seven days for each, confrmation and includes detailed information about patents, reporting). Eisai does not engage in voluntary licensing nor has it issued non-assert declarations for Has policy for responding to emergencies or products in scope. While Eisai did not make sider granting non-exclusive voluntary licences in any ad hoc donations during the period of analycertain circumstances. The company tracks the assets with third-party researchers developing delivery of the product until received by end products for diseases in scope. As of June 2017, Eisai reports that over ther fle for nor enforce patents related to dis1. Foreign Corrupt Practices Act concerning improper payments to healthcare professionals in China. Has the largest pipeline with a process for Performance by strategic pillar access-planning, but does not disclose project-specifc access plans for its late-stage projects. Substantial increase in the coverage of the One of nine company’s portfolio with equitable pricing strategies.

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Fungal infection with zygomycosis (mucormycosis) is an important concern in immunosuppressed patients arrhythmia kamaliya 10mg amlodipine overnight delivery. Similar to hypertension silent killer cheap amlodipine online visa otitis media blood pressure 35 year old female cheap amlodipine online master card, a large percentage (up to blood pressure medication for adhd buy 5 mg amlodipine with mastercard 60%) of children with clinically diagnosed sinusitis based on persistent symptoms will resolve without antibiotics. The definitive study to evaluate the benefits of antibiotics—a randomized, placebo-controlled trial with pretreatment and posttreatment cultures from sinus aspirates—has not been done. Treatment is empirical and is recommended for severe symptoms in the early stages or clear persistence without improvement beyond 10 to 14 days to hasten recovery and prevent suppurative complications. American Academy of Pediatrics Subcommittee on Management of Sinusitis: Clinical practice guideline: management of sinusitis, Pediatrics 108:798–808, 2001. The duration of therapy for acute sinusitis in children has not been studied systematically. However, for patients whose symptoms improve dramatically within 3 to 4 days of initiating treatment, a 10-day course of therapy is usually effective. For patients who respond more slowly to antibiotics, treatment until symptoms resolve plus another 7 days is reasonable. The Mantoux test is interpreted in the context of clinical signs and symptoms and epidemiologic risk factors. Why is a multiple puncture test (tine test) not considered an ideal test for tuberculosisfi Shingadia D, Novelli V: the tuberculin skin test: a hundred, not out, Arch Dis Child 93:189–190, 2008. History should search for clues that are suggestive of active infection, such as recurrent fevers, weight loss, adenopathy, or cough. Epidemiologic information includes an evaluation of possible exposure to tuberculosis. A family history is obtained, including questions pertaining to chronic cough or weight loss in a family member or other contact. Laboratory evaluation, including a chest radiograph with a lateral film, is the next stage. In certain circumstances, chest radiographs should be performed on the child’s contacts. If any of the preceding evaluation suggests active infection, sputum, gastric aspirates, and other appropriate specimens. If a patient has never received antituberculous medication and has not had a known exposure to a person with isoniazid-resistant tuberculosis, that patient should be treated with isoniazid, once daily, for 9 months. Adherence to this regimen has been found to have an efficacy near 100% in preventing disease. In a younger child suspected of having tuberculosis disease, how should gastric aspirates be obtainedfi Because children younger than 10 years rarely produce sputum, gastric aspirates are a better source for the culture of mycobacteria in these patients, yielding the organism in up to 40% of cases. The aspirate should be obtained early in the morning as the child awakens to sample the overnight accumulation of respiratory secretions. The sample should be collected in a saline-free fluid, and the pH should be neutralized if any delay in processing is anticipated because M. How do the manifestations of active pulmonary tuberculosis on chest radiograph differ between adults and childrenfi Adults more commonly present with cavitary disease compared with children who have hilar adenopathy. Children older than 5 years tend to be asymptomatic, whereas infants with hilar adenopathy have air trapping and wheezing thought to result from the smaller bronchi being more easily compressed by enlarging lymph nodes. Janner D: A Guide to Pediatric Infectious Disease, Philadelphia, 2005, Lippincott Williams & Wilkins, p 126. Recommendations for the treatment of active tuberculosis in children have evolved over the past several years. Previously, therapy for at least 9 months was suggested for uncomplicated pulmonary disease. Studies in adults and children have demonstrated that 6 months of combined antituberculous therapy (short-course therapy) is as effective as 9 months of therapy. To date, the combined results of multiple studies in pediatric patients have demonstrated the efficacy of 6 months of therapy to be more than 95%. Ifdrug resistanceisa concern,eitherethambutol orstreptomycin is added to the initial three-drug regimen until drug susceptibilities are determined. Failure to properly take chronic medications increases the likelihood of relapse and the development of resistance. Compared with a patient with only a positive test but no disease, two features of M. First, mycobacteria replicate slowly and may remain dormant for prolonged periods, but they are susceptible to drugs only during active replication. Second, drug-resistant organisms exist naturally within a large population, even before the initiation of therapy. These features render the organism—when it is present in significant numbers—extremely difficult to eradicate with a single agent. Isoniazid interferes with pyridoxine metabolism and may result in peripheral neuritis or convulsions. The administration of pyridoxine is generally not necessary for children who have a normal diet because they have adequate stores of this vitamin. Depending on the population studied, efficacy against tuberculosis has ranged from 0% to 80%. Similarly, the efficacy against leprosy has ranged from 20% to 60% in prospective trials. The vaccines were derived from a strain of Mycobacterium bovis in 1906 and were subsequently dispersed to several laboratories around the world, where they were propagated under nonstandardized conditions. If positive, consideration should be given to several factors when deciding who should receive antituberculous therapy. Tuberculosis is transmitted by infected droplets of mucus that become airborne when an individual coughs or sneezes. In addition to tuberculosis, what other airborne microbes can cause respiratory diseasefi Should an asymptomatic infant with a single umbilical artery have a screening ultrasound done for renal anomaliesfi In one study of nearly 35,000 infants, examination of the placenta showed that only 112 (0. However, isolated single umbilical artery in an otherwise normal infant is associated with a low incidence of renal and urinary tract anomalies, most of which are transient or mild. Doornebal N: Screening infants with an isolated single umbilical artery for renal anomalies: nonsensefi Rittler M et al: Single umbilical artery and associated malformations in over 5,500 autopsies. How does the handling of the umbilical cord at birth affect neonatal hemoglobin concentrationsfi At the time of birth, the placental vessels may contain up to 33% of the fetal-placental blood volume. Constriction of the umbilical arteries limits blood flow from the infant, but the umbilical vein remains dilated. The extent of drainage from the placenta to the infant through the umbilical vein is very dependent on gravity. The recommendation is to keep the baby at least 20 to 40 cm below the placenta for about 30 to 60 seconds before clamping the cord. Delayed clamping (>1 minute) resulted in short-term increases in hemoglobin, jaundice requiring phototherapy, and higher ferritin levels at 6 months. What is the best method of umbilical cord care during the immediate neonatal periodfi No single method of cord care has been determined to be superior for preventing colonization and infections. Antimicrobial agents, such as bacitracin or triple dye, are commonly used, but there are no efficacy data (other than reduced colonization). Alcohol accelerates the drying of the cord, but it has not been shown to reduce the rates of colonization or omphalitis. Therefore, simply cleaning with normal saline and allowing the cord to dry normally appears to be as safe and effective as using antibiotics. However, because neutrophilic and monocytic infiltration appear to play a major role in autodigestion, persistence of the cord beyond 30 days should prompt consideration of an underlying functional abnormality of neutrophils (leukocyte adhesion deficiency) or neutropenia.

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Megakaryocyte counts are reduced under the effects of all toxic stimuli on bone marrow blood pressure medication for acne discount amlodipine online master card. Counts increase after bleeding heart arrhythmia xanax purchase amlodipine 5mg without a prescription, in essential thrombocytopenia (Werlhof syndrome) blood pressure tea order cheap amlodipine online, and in myeloproliferative diseases (chronic myeloid leukemia heart attack 1d lyrics discount amlodipine 2.5mg, polycythemia, and essential thrombocythemia). Perls’ Prussian blue (also known as Perls’ acid ferrocyanide reaction) shows the presence of ferritin in 20–40% of all normoblasts, in the form of one to four small granules. Greater numbers of ferritin granules in normoblasts indicate a disorder of iron utilization (sideroachresia, especially in myelodysplasia), particularly when the granules form a ring around the nucleus (ring sideroblasts). Perls’ Prussian blue reaction also stains the diffuse iron precipitates in macrophages. Under exogenous iron deficiency conditions the proportion of sideroblasts and iron-storing macrophages is reduced. However, if the shift in iron utilization is due to infectious and/or toxic conditions, the iron content in normoblasts is reduced while the macrophages are loaded with iron to the point of saturation. In hemolytic conditions, the iron content of normoblasts is normal; it is elevated only in essential or symptomatic refractory anemia (including megaloblastic anemia). Not just the individual cell, but its relative proportion is relevant in bone marrow diagnostics a b c d. Compare (differential diagnosis) with the plasma cell (4) with its eccentric nucleus. When present, they are most likely to appear as dense cell groups with long fiber-forming cytoplasmic processes and small nuclei. Iron staining shows them up as a group of reticular cells which, like macrophages, have the potential to store iron. If they become the prominent cell population in the bone marrow, an aplastic or toxic medullary disorder must be considered. Because of their small nuclei and easy-flowing cytoplasm, they are noticeable after panoptic staining only when they contain obvious entities such as lipids or pigments. They differ from plasma cells in that the cytoplasm has no perinuclear lighter space (cell center) and stains a cloudy grayish-blue. As they are normally rare in bone marrow, increased presence of osteoblasts in the marrow may indicate metastasizing tumor cells (from another location). They are normally extremely rare in aspirates, and when they are found it is usually under the same conditions as osteoblasts. They are distinguished from megakaryocytes by their round and regular nuclei and by their lack of thrombocyte buds. From the above, it will be seen that bone marrow findings can be assessed on the basis of a knowledge of the cells elements described above (p. It also shows that a diagnosis from bone marrow aspirates can safely be made only in conjunction with clinical findings, blood chemistry, and the qualitative and quantitative blood values. For this reason, a table of diagnostic steps taking account of these categories is provided at the beginning of each of the following chapters. The features that distinguish osteoblasts from plasma cells are their more loosely structured nuclei and the cloudy, “busy” basophilic cytoplasm. Abnormalities of the hite Cell Series Theml, Color Atlas of Hematology © 2004 Thieme All rights reserved. However, this old method does allow the relevant differential diagnosis to be inferred from a cursory screening of a slide. Differential Diagnostic Notes Differential diagnosis when round to oval cells predominate Reactive lymphocytoses and monocytoses, pp. Predominance of Mononuclear Round to Oval Cells 63 Predominance of Mononuclear Round to Oval Cells (Table5) the cell counts (per microliter) show a wide range of values and depend on a variety of conditions even in normal blood. Any disease may therefore result in higher (leukocytosis) or lower cell counts (leukopenia). The assessment of cell counts requires the knowledge of normal values and their ranges (spreads) (Table 2, p. The most important diagnostic indicator therefore is not the cell count but the cell type. In a first assessment, mononuclear (round to oval) and polynuclear (segmented) cells are compared. This is the first step in the differential diagnosis of the multifaceted spectrum of blood cells. Absolute or relative predominance of mononuclear cells points to a defined set of diagnostic probabilities. Consequently, the most important step is to distinguish between lymphatic cells and myeloid blasts. The nuclear morphology makes it possible to distinguish between the two cell types. In lymphatic cells the nucleus usually displays dense coarse chromatin with slate-like architecture and lighter zones between very dense ones. In contrast, the immature cells in myeloid leukemias contain nuclei with a more delicate reticular, sometimes sand-like chromatin structure with a finer, more irregular pattern. Predominance of Mononuclear Round to Oval Cells 65 ThromboElectroTentative Evidence/advanced BonemarRef. This is usually seen as enlarged nuclei, a moderately loose, coarse chromatin structure, and a marked widening of the basophilic cytoplasmic layer. Clinical findings, which include acute fever symptoms, enlarged lymph nodes, and sometimes exanthema, help to identify a lymphatic reactive state. Unlike the case in acute leukemias, erythrocyte and thrombocyte counts are not significantly reduced. Although the granulocyte count is relatively reduced, its absolute value (per microliter) rarely falls below the lower limit of normal values. Morphologically normal lymphocytes predominate in the blood analyses in the following diseases: Whooping cough (pertussis) with clear leukocytosis and total lymphocyte counts up to 20000 and even 50000/µl; occasionally, slightly plasmacytoid differentiation. The cell morphology ranges from basophilic plasmacytoid cells to typical plasma cells. Some of the cells may resemble myelocytes, but their chromatin is always denser than myelocyte chromatin. Varying proportions of the mononuclear cells (at least 20%) may be rather extensively transformed round cells (Pfeiffer cells, virocytes). Immunological markers are necessary to ascertain that these are stimulated lymphocytes (mostly T-lymphocytes) defending the B-lymphocyte stem population against the virus attack. The nuclei of these stimulated lymphocytes are twoto three-fold larger than those of normal lymphocytes and their chromatin has changed from a dense and coarse structure to a looser, more irregular organization. The cytoplasm is always relatively wide and more or less basophilic with vacuoles. In the course of the disease, the degree of transformation and the proportions of the different cell morphologies change almost daily. A slight left shift and elevated monocyte count are often found in the granulocyte series. Acute leukemia is often considered in the differential diagnosis in addition to other viral conditions, because the transformed lymphocytes can resemble the blasts found in leukemia. Absence of a quantitative reduction of hematopoiesis in all the blood cell series, however, makes leukemia unlikely, as do the variety and speed of change in the cell morphology. Characteristics of Infectious Mononucleosis Age of onset: School age Clinical findings: Enlarged lymph nodes (rapid onset), inflammations of throat and possibly spleen! Differential diagnosis: Lymphomas (usually without fever), leukemia (usually Hb ", thrombocytes ") Persistent disease (more than 3 weeks): possibly test for blood cell markers, lymph node cytology (#histology) Course, treatment: Spontaneous recovery within 2–4 weeks; general palliation Theml, Color Atlas of Hematology © 2004 Thieme All rights reserved. Extreme transformation of lymphocytes leads to blast-like cells: mononucleosis a b c d. An exception is the lymphoblastic lymphoma, which takes its course as an acute lymphocytic leukemia. The modern pathological classification of lymphomas is based on morphology and cell immunology. The surface markers are identified in immunocytological tests (Table 7) carried out on heparinized blood or bone marrow spicules.

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Avulsion is the separation and removal of the nail plate (11730 hypertension yahoo discount amlodipine 5mg on-line, 11732) heart attack like symptoms buy 2.5mg amlodipine fast delivery, preserving the root so the nail will grow back pulse pressure of 53 discount amlodipine 2.5mg with amex. An anesthetic is administered blood pressure monitor watch buy on line amlodipine, the nail is lifted away from the nail bed, and a portion or all of the nail plate is removed. C O D I N G S H O T Do not use modifier -51 (multiple procedures) with nail removal codes, as there are two codes available: one for a single nail and one for each additional nail. For example, if three nails were removed, you would report: 11730 (for the first nail) and 11732 fi 2 (for the second and third nails). A subungual hematoma (blood trapped under the nail) is evacuated by puncturing the nail with an electrocautery needle (11740). The trapped blood and fluid are drained by applying pressure to the top of the nail. Onychocryptosis (ingrown toenail) is the most common condition of the great toe, as illustrated in. The nail grows down and into the soft tissue of the nail fold, causing extreme pain and often infection. Treatment for severe cases is a partial onychectomy (removal of the nail plate and root). The toe is anesthetized and a portion of the nail plate and root is removed (11750). For example, nail biopsies (11755) were performed on the left third finger (F2) and the left fourth finger (F3), in addition to the right fourth digit (F8). Pilonidal cyst the codes for the excision of a pilonidal cyst or sinus are 11770-11772. A pilonidal cyst is located in the sacral area and is most often caused by an ingrown hair. The codes are divided according to the complexity of the excision—simple, extensive, or complicated. For a simple cyst, the physician would excise the cyst and suture the skin together. A cyst larger than 2 cm is considered complicated and requires more extensive excision and closure. A complicated excision is very extensive and usually requires reconstructive surgical repair. Introduction Within the Introduction category of codes (11900-11983) are lesion injection, tattooing, tissue expansion, contraceptive capsule insertion/removal, and hormone implantation services. Lesions are injected with medication to treat conditions such as acne, keloids (scar tissue), and psoriasis (autoimmune disorder that results in scaly patches). Lesion injection codes are divided according to the number of lesions injected (1-7 or 8+). You report 11900 for lesion injections numbering one through seven, and 11901 to report injections eight and more. Codes for subcutaneous injection of filling material (11950-11954) are located in the Introduction category and are reported for services such as collagen or silicone injections (injectable dermal implants) used as a wrinkle treatment. The procedure is usually repeated at 2 to 3 week intervals until the results are those desired. Tissue-expander codes (11960-11971) are also located in the Introduction category and report tissue expanders. A tissue expander is an elastic material formed into a sac that is then filled with fluid or air so it expands like a balloon. Expanders are also used to assist in the repair of scars and the removal of tattoos by stretching the skin, removing the expander, removing the scar or tattoo, and suturing the skin edges together. The codes are divided according to whether the service is an insertion, a removal, or an expander removal with replacement of a prosthesis. C O D I N G S H O T Do not report an expander code from the Introduction category after a mastectomy in which a temporary expander has been inserted. Code 19357 from the reconstruction section of the Integumentary subsection is a combination of the mastectomy and insertion of an expander. If at a later date the expander was replaced with a permanent prosthesis, you would report replacement of tissue expander with permanent prosthesis with 19342. You will also find insertion of implantable contraceptive capsules in the Introduction category. Implantable contraceptive capsules are inserted under the skin by means of a small incision on the upper arm. A capsule is effective for a number of years; at the end of that time, it must be removed. Read the descriptions in the implantable contraceptive capsule codes (11976-11981) carefully, as there are codes for insertion and removal. Subcutaneous hormone pellet implantation is commonly used for the insertion of a hormone in a time-release capsule into the buttocks of women requiring hormone replacement therapy after menopause. The pellet is completely absorbed into the system and does not need to be removed, as does a contraceptive capsule. However, a new pellet must be inserted every 6 to 9 months, and each reinsertion is reported separately. Simple: Superficial wound repair (12001-12021) that involves epidermis, dermis, and subcutaneous tissue. If the simple wound repair is accomplished with tape or adhesive strips, the charge for the closure is included in the E/M service code and would not be reported separately with a repair code. Intermediate: Requires closure of one or more layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin closure. You can report intermediate closure (12031-12057) when the wound has to be extensively cleaned, even if the closure was a single-layer (simple) closure. Complex: Involves complicated wound closure including revision, debridement, extensive undermining, stents or retention sutures, and more than layered closure (13100-13160). F r o m t h e T r e n c h e s “[It’s my job] to make sure physicians are saying [everything] into their microrecorder, or writing it down. You would be surprised how many physicians [diagnose a patient] mentally, as an automatic thing as part of their evaluation of the patient’s condition—then they do the medical decision making on how to treat the patient. Sometimes a third of it doesn’t even get put down, and the coder can only count that third of information, until it’s in the record. I’ve told doctors ‘You dictated this, and this is all you’re going to get’ so they can see the consequences. Most other third-party payers use the simple repair code to report skin closures using adhesives. For each anatomic site, the lengths of wounds are totaled together by complexity (simple, intermediate, complex). All the simple wounds of the same site grouping are reported together; all the intermediate wounds of the same site grouping are reported together; and all the complex wounds of the same site grouping are reported together. For example, 12001 groups superficial scalp, neck, axillae, external genitalia, trunk, and extremities (including hands and feet). When there is more than one repair type, the most complex type is listed as the first (primary) procedure. The secondary procedure is then reported using modifier -59 (distinct procedural service). C A U T I O N For repairs: • Group together the same anatomic sites, such as face and hand. Repair component Three things are considered components (parts) of integumentary wound repair: 1. Simple ligation (tying) of small vessels is considered part of the wound repair and is not reported separately. Simple ligation of medium or major arteries in a wound is, however, reported separately. Simple exploration of surrounding tissue, nerves, vessels, and tendons is considered part of the wound repair process and is not listed separately. Normal debridement (cleaning and removing skin or tissue from the wound until normal, healthy tissue is exposed) is not listed separately. If the wound is grossly contaminated and requires extensive debridement, a separate debridement procedure may be assigned (11000-11047 for extensive debridement). Tissue transfers, grafts, and flaps There are many types of grafting procedures that can be performed to correct a defect. To understand skin grafting, you must know that the recipient site is the area of defect that receives the graft, and the donor site is the area from which the healthy skin has been taken for grafting.

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