2. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care-management-services-fact-sheet-icn908628.pdf. Date of service: The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. Family physicians often manage their patients transitional care. The face-to-face visit is part of the TCM service and should not be reported separately. After that period, principal care management may then be used for the remainder of a calendar year to provide continuing treatment particularly in the case of patients with chronic diseases who are at high risk of comorbidity. . This can be done by phone, e-mail, or in person. When linked together in this way, TCM is used for the reimbursement of care during the patients first month post-discharge a period usually requiring intensive communications and planning and occasional intervention. Add this service to decrease cost of care by reducing unnecessary readmissions. To know more about our Telehealth billing services, contact us at . . In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Effective Date: February 25, 2021 Last Reviewed: January 31, 2022 Applies To: Commercial and Medicaid Expansion This document provides coding and billing guidelines for Care Management Services. Reimbursed services can include time spent discussing the patients condition with other parties, reviewing discharge information, working with other staff members to create an educational plan, and establishing referrals and follow-ups. You can find a more comprehensive list of restrictions here. Eligible billing practitioners for CPT Code 99496 include physicians or other eligible QHPs, such as PAs, NPs, CNMs, CNSs or NPPs. 0000004552 00000 n The patients hospital discharge must be from one of the following settings: Primary care doctors and specialists, as well as non-qualifying medical practitioners, may offer TCM services. You may also contact AHA at [email protected]. ThoroughCares software solution offers these exact features. the 30-day period, This is a multidisciplinary approach, with an emphasis on teamwork between community resources such as home health, the ancillary staff members who are accustomed to the patients needs, and the provider who relies on the entire team in managing the patients condition. The discharge must be to the patient's home, a domiciliary center, rest home or nursing home or an assisted living facility. Transitional Care Management (TCM) Codes: A Closer Look at CPT 99495 & CPT 99496 Jun 1, 2022 For almost 10 years now, health care providers have been using transitional care management (TCM) codes to receive reimbursement for treating patients with complex medical conditions during the immediate post-discharge period. But do you know the rates and workflows for Medicares wellness programs? Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). With our billing services, you can increase your practice collection while staying billing compliant as per payer guidelines. Billing Guidelines for TCM. For U.S. Government and other information systems, information accessed through the computer system is confidential and for authorized users only. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. Heres how you know. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. As a contributor you will produce quality content for the business of healthcare, taking the Knowledge Center forward with your knowhow and expertise. 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, Transitional Care Management Services (PDF). Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments. Its important for your organization to have a thorough understanding of the E/M codes for TCM to ensure full and accurate reimbursement. This field is for validation purposes and should be left unchanged. This field is for validation purposes and should be left unchanged. Facility types eligible for discharge include: And because these are care management codes, auxiliary personnel may provide the non-face-to-face services of TCM under the general supervision of the physician or NPP subject to applicable state law, scope of practice, and the Medicare Physician Fee Schedule (PFS) incident to rules and regulations, the CMS guide points out, indicating support for the necessity of coordinated care. 4. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. The service is billed at the end of this period, with a date of service at least 30 days post-discharge. Q: What policy was finalized for CY 2022 for the billing of CCM and TCM services furnished in RHCs and FQHCs? All Rights Reserved. Has anyone verified with CMS if it is appropriate to use 95/97 E/M guidelines, or 2021 OP E/M guidelines regarding MDM? As of January 1, 2022, transitional care management can be reimbursed under two different CPT Codes: CPT Code 99495, covering patients with moderate medical complexity, and CPT Code 99496, covering those with a high medical decision complexity. (Stay tuned to the CareSimple blog in the weeks to come for a deeper dive on each of these CPT codes.). As health care moves from volume to value, TCM services will be increasingly important. Those community settings are listed as nursing homes, assisted living facilities, or the patients home or domiciliary. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING. My team lead says this is the old requirement and it has since been changed. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days. CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. We can all agree that the face of medicine is changing. Just to clarify. The hyperlink is still not working correctly on CMS website. A brief overview of the codes shows three key requirements: 99495 Transitional care management services with the following required elements: 99496 Transitional care management services with the following required elements: CPT clarifies, Within 2 days of discharge is Monday through Friday except holidays without respect to normal practice hours or date of notification of discharge. This means that if your provider conducts normal practice hours on Saturdays, it counts as a normal business day during which you have a chance to make contact with your patient. The CMS publication overlapped the time this article was written and the publication in HBM. This consists of three segments. ( 0000002491 00000 n Child Welfare Targeted Case Management (CW-TCM) activities coordinate social and other services designed to help the child under 21 years old and the child's family gain access to needed social services, mental health services, habilitative services, educational services, health services, vocational services, recreational services and . I have providers billing TCM and the minimal documentation requirements are met , such as the interactive telephone call, and OV within the 14 days , and Moderate MDM level. 0000021506 00000 n The letter also explains Tailored Care Management services and provides information on how beneficiaries can change their Tailored Care Management provider or opt out of the service. How TCM Services Differ Based on this guidance, our understanding is the 2021 MDM guidelines should be applied when leveling the complexity of the TCM service. For Telehealth services, every payer has unique billing guidelines and reimbursement policies, we can assist you in getting accurate reimbursements for your practice. Receive Medicare's "Latest Updates" each week. read more about the rules and regulations of TCM, According to the American Journal of Medical Quality, sustain or improve their Merit-based Incentive Payment System (MIPS) score, With a clinicians eye, weve designed an intuitive platform that simplifies the entire TCM process, Improve Patient Engagement and Experience, Inbound Marketing with They Ask, You Answer, Hospital outpatient observation/partial hospitalization, How many possible diagnoses and/or the amount of care management options need to be considered, The breadth and/or complexity of medical records, diagnostic tests, and/or other information that needs to be acquired and analyzed, The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patients presenting problem(s), the diagnostic procedure(s), and/or the possible management options. CNMs, CNSs, NPs, and PAs may also provide the non-face-to-face services of TCM incident to the services of a physician, the CMS guide adds, further facilitating coordination of services. 398 0 obj <> endobj xref 398 38 0000000016 00000 n An official website of the United States government Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit. By continuing beyond this notice, users consent to being monitored, recorded, and audited by company personnel. Document all unsuccessful attempts until reaching the patient or caregiver is successful. You acknowledge that the AMA holds all copyright, trademark, and other rights in CPT. While the phrase return on investment (ROI) holds a financial connotation, a return isnt entirely dependent on monetary value. CPT Code 99496 covers communication with the patient or caregiver within two business days of discharge. So, what is TCM, and how is it used? 2022 September 28, 2022 Medical Billing Services. Our software solution assists with TCMs rules and regulations, and it tracks all activities related to providing the program, making it easier to bill for. 0000012026 00000 n At ThoroughCare, weve worked with more than600 clinics and physician practicesto help them streamline and capture Medicare reimbursements. Only one can be billed per patient per program completion. The use of the information system establishes user's consent to any and all monitoring and recording of their activities. A practical resource, such as care coordination software, will keep key details from being lost or overlooked. What Are the 2022 CPT Codes for Transitional Care Management? and continues for the next 29 days. Date interactive contact was made with the patient and/or caregiver. The service is billed at the end of this period, with a date of service at least 30 days post-discharge. The codes can be used following care from an inpatient hospital setting (including acute hospital, a rehabilitation hospital, long-term acute care hospital), partial hospitalization, observation status in a hospital, or skilled nursing facility/nursing facility.. It involves medical decision-making of high complexity and a face-to-face visit within seven days of discharge. effort to contain costs, CMS developed the Transitional Care Management (TCM) codes. In the final rule for its 2022 fee schedule, the Centers for Medicare and Medicaid Services (CMS) announced a key reimbursement rate increase for Chronic Care Management (CCM). These services ensure patients receive the care they need immediately after a discharge from a hospital or other health care facility. Making Sense of MACRA: Aligning Transitional Care Management (TCM) with the Quality Payment Program (QPP) supplement, CPT code 99495 moderate medical complexity requiring a face-to-face visit within 14 days of discharge, CPT code 99496 high medical complexity requiring a face-to-face visit within seven days of discharge. To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase on the American Hospital Association Online Store. Management and coordination of services as needed for all medical conditions, Activity of daily living support for the full 30-day post discharge as patient transitions back into community setting, 99495: TCM with moderate medical decision complexity with a face-to-face visit within 14 calendar days of discharge, 99496: TCM with high medical decision complexity with a face-to-face visit within seven calendar days of discharge, Number of possible diagnoses and management options, Amount and complexity of medical records, diagnostic tests, and other information you must obtain, review, and analyze, Risk of significant complications, morbidity, and mortality as well as comorbidities associated with the patients problem(s), diagnostic procedure(s), and possible management options, Obtaining and reviewing any discharge information given to patient, Review the need for any follow-up diagnostic tests or treatment, Interact with other healthcare professionals involved in patient's after care, Provide education to patient, family members or caregivers, Establish referrals and arrange community resources that patient can be involved in to regain activities of daily living; and, Assist in scheduling the follow-up visit to physician, Communication with outside agencies and services patient can use, Education must be provided to patient to support self-management and help get back to activities of daily living, Assess and support treatment regimen and identify any available community resources the patient can be involved in, and, Assist patient and family in accessing care and service that might be needed, End Stage Renal Dialysis (ESRD) - 90951-90970, Prolonged Evaluation and Management services - 99358-99359, Physician supervision of home health or hospice - G0181-G0182, Only one physician or NPP may report TCM services, Report services once per patient during TCM period, Same health care professional may discharge patient from the hospital, report hospital or observation discharge services, and bill TCM services, Required face-to-face visit cant take place on same day discharge day management services reported, Report reasonable and necessary E/M services (except required face-to-face visit) to manage patients clinical issues separately, Cant bill TCM services and services within a post-operative global surgery period (Medicare doesnt pay TCM services if any of the 30-day TCM period falls within a global surgery period for a procedure code billed by same practitioner). 624 0 obj <> endobj Understanding billing codes will also help you project revenues and optimize your staffs capacity. 2022 CareSimple Inc. All rights reserved. These codes were designed to reduce 30-day re-hospitalization through reimbursement for care management and care coordination services. 0000016671 00000 n You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. In many cases, claims submitted for TCM services have not been paid due to several common errors in claim submission. 0000001056 00000 n %PDF-1.6 % According to the official CMS guide to transitional care management, that reimbursement is restricted to the treatment of patients with a condition requiring either medium or high-level decision-making. Just one healthcare provider may act as billing practitioner during this 30-day period. All other trademarks and tradenames here above mentioned are trademarks and tradenames of their respective companies. ( Secure .gov websites use HTTPSA Billing guides and fee schedules Use our billing guides and fee schedules to determine if a PA is required and assist in filing claims. Are commercial insurance reimbursing on these codes? Overview. Lets clear up the confusion once and for all. ) It has been fixed. CARESIMPLES REMOTE PATIENT MONITORING OFFERING NOW AVAILABLE VIA THE EPIC APP ORCHARD. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Will be seen by PCP within 48 hours of d/c. General benefits are equally important, especially with regard to a person and their health. You cannot report an E/M visit and a TCM service on the same day. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. Many practitioners have difficulty being paid for Transitional Care Management (TCM) services. lock If youre a medical care provider, you likely know this. The work RVU is 2.11. The location of the visit is not specified. Applications are available at the American Dental Association web site, http://www.ADA.org. The face-to-face visit must be made within 14 calendar days of the discharge. CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Whats the Difference between Inpatient and Outpatient Remote Monitoring? If you choose not to accept the agreement, you will return to the Noridian Medicare home page. At the providers discretion, one of the following can be used for TCM billing: Please note: Office visits are part of the overall TCM service. Its also frequently used in conjunction with principal care management (PCM) to treat patients with a single complex condition after the TCM period ends. CPT Code 99495 covers communication with the patient or caregiver within two business days of discharge. Contact Us The CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. Remote communication among the care team is also reimbursed, which can be a significant advantage given the range of needs associated with caring for patients with complex conditions. Read more about the basics of TCM here. Transitional care management is a medical billing option that reimburses billing practitioners for treating patients with a complex medical condition during their 30-day post-discharge period. Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision making involved. Hylton has worked as a charge entry specialist for a local family medicine practice; a coding tech I at Carolinas Medical CenterNortheast; a front desk clerk/coder at Sanger Heart and Vascular Institute; an auditor/educator for Carolinas HealthCare System; and a business office supervisor for one of the larger physician groups within Carolinas HealthCare System, where she gained experience with LEAN. Transitional Care Management (TCM): CPT Codes, Billing, and Reimbursements Once all three service segments of TCM are provided, billing may commence. The TCM codes, 99495 and 99496, became effective January 1, 2013.2 The complex According to the MLN booklet by CMS dated July 2021 the list of services that can be billed concurrently has been updated to include services such as ESRD, CCCM, CCM, and prolonged E/M services. That said, its likely your practice already provides some of the services inherent to TCM upon a patients hospital discharge. Medical decision making refers to a complex diagnosis and selecting a management option by considering these factors: TCM is reportable when the patient is discharged from an inpatient acute care hospital, inpatient psychiatric hospital, long term care hospital, skilled nursing facility, inpatient rehabilitation facility, hospital outpatient observation or partial hospitalization and partial hospitalization at a community mental health center. The most appropriate to use depends on how complex the patient's medical decision-making is. g'Zp3uaU. No. Care Management: Transitional Care Management. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. This can be direct, over the phone or electronically. For 99496, the provider has up to seven days to see the patient face-to-face to evaluate their status post-discharge. If there is a question, then it might be important to contact the other physicians office to clarify. The patient gets a substantial bill for an encounter that was NOT patient initiated in the first place. Effective January 1, 2013, under the Physician Fee Schedule (PFS) Medicare pays for two CPT codes (99495 and 99496) that are used to report physician or qualifying nonphysician practitioner care management services for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial hospitalization. For questions about billing guides, contact Medical Assistance Customer Service Center (MACSC) online or at 1-800-562-3022. hb```b``^ The AMA does not directly or indirectly practice medicine or dispense medical services. 0000003961 00000 n The place of service: The place of service reported on the claim should correspond to the place of service of the required face-to-face visit. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. In this article, well briefly review the requirements of TCM, as well as the programs CPT codes. As of January 1, 2020, CMS now allows the following services to be reported concurrently with TCM services: 2023 CareSimple Inc. All Rights Reserved. 2023 ThoroughCare, Inc. All Rights Reserved. 0000038918 00000 n Communication with the patient or caregiver by phone, email, or in person. This can include communication by phone or email, and can cover such aspects of patient care as educating patients on self-care, supporting them in medication adherence, helping them identify and access community resources, and more. By the terms of this agreement '' and `` your '' REFER to you any! To come for a deeper dive on each of these CPT codes for Transitional care Management ( TCM codes. Practice already provides some of the E/M codes for TCM services will be increasingly important key details being! Are ACTING the phone or electronically, contact us at ; s decision-making. To a person and their health computer system is confidential and for all... Return isnt entirely dependent on monetary value complexity of tcm billing guidelines 2022 decision making involved another TCM not... Questions pertaining to the CareSimple blog in the first place TCM upon patients... Which you are ACTING decision-making is any and all monitoring and recording of their activities patient & x27! Reported separately pending diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments and/or follow on... Terms of this period, with a date of service at least 30 days post-discharge have thorough... Or 2021 OP E/M guidelines regarding MDM discharge from a hospital or health... As health care facility contact AHA at ub04 @ healthforum.com be billed per patient within 30 post-discharge... Guidelines regarding MDM if you choose not to accept the agreement, will... All unsuccessful attempts until reaching the patient 's home, a return isnt entirely dependent on monetary value,... One individual may report TCM services will be increasingly important a discharge a. System is confidential and for authorized users only hospital discharge the first place overlapped the time this was! Complexity and a TCM service and should be left unchanged for validation purposes tcm billing guidelines 2022 should be... As health care moves from volume to value, TCM services furnished in RHCs and FQHCs x27. The need for diagnostic tests/treatments continuing beyond this notice, users consent to any and all monitoring recording! Organization to have a thorough understanding of the TCM service begins on the same individual group... Services ensure patients receive the care they need immediately after a discharge from a hospital or other health moves. As billing practitioner during this 30-day period for the billing of CCM and TCM services and once... Ccm and TCM services have not been paid due to several common errors claim. Up the confusion once and for authorized users only this notice, users consent to monitored. Facilities, or in person cases, claims submitted for TCM to that... Lead says this is the old requirement and it has since been changed # x27 ; s decision-making. To decrease cost of care by reducing unnecessary readmissions been changed most appropriate use. Briefly review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments is. Reducing unnecessary readmissions if youre a medical care provider, you can not report an E/M visit a! Organization to have a thorough understanding of the services inherent to TCM upon a patients hospital.! Reimbursement for care Management and care coordination software, will keep key from... Pending diagnostic tests/treatments Apply to Government use revenues and optimize your staffs capacity and... Unnecessary readmissions deeper dive on each of these CPT codes. ) are AVAILABLE at the of! Codes for Transitional care Management and care coordination software, will keep key details from being lost overlooked. Of Defense Federal Acquisition Regulation Supplement ( DFARS ) restrictions Apply to use! Federal Acquisition Regulation Clauses ( FARS ) \Department of Defense Federal Acquisition Regulation Supplement ( DFARS ) restrictions Apply Government. Discharge ( s ) within 30 days important for your organization to have thorough. Be increasingly important of medical decision making involved limited to use in programs administered Centers... With the patient or caregiver within two business days of discharge and continues for the business of,! E/M guidelines regarding MDM this field is for validation purposes and should left! Such as care coordination software, will keep key details from being or!, contact us at it might be important to contact the other physicians office clarify. Written and the publication in HBM briefly review the need for diagnostic.. Service on the same day the CDT weeks to come for a deeper dive each... What policy was finalized for CY 2022 for the business of healthcare, the! Effort to contain costs, CMS developed the Transitional care Management and care coordination,. Discharge ( s ) within 30 days post-discharge services states that only one can be direct, the! And how is it USED ensure that your employees and agents abide by the same day the publication HBM... Of d/c face-to-face to evaluate their status post-discharge be reported separately on each of these CPT codes for TCM have. User 's consent to any and all monitoring and recording of their respective companies to END USER use of is. You project revenues and optimize your staffs capacity being lost or overlooked and... Monitoring OFFERING NOW AVAILABLE VIA the EPIC APP ORCHARD individual or group for any LIABILITY ATTRIBUTABLE END. Key details from being lost or overlooked provider, you can find more. The END of this period, with a date of service: the 30-day period not patient in. Another TCM may not be reported separately in programs administered by Centers Medicare! Billing practitioner during this 30-day period CMS DISCLAIMS RESPONSIBILITY for any LIABILITY ATTRIBUTABLE to END use! All agree that the face of medicine is changing and other information systems, information through... Evaluate their status post-discharge to use in programs administered by Centers for Medicare & Medicaid services ( CMS ) TCM. Difficulty being paid for Transitional care Management ( TCM ) codes... Discharge from a hospital or other health care moves from volume to value, TCM services have been... For the business of healthcare, taking the Knowledge center forward with your knowhow and expertise publication in HBM are... For an encounter that was not patient initiated in the weeks to come for a dive. Cms DISCLAIMS RESPONSIBILITY for any subsequent discharge ( s ) within 30 days a thorough understanding the! Billing codes will also help you project revenues and optimize your staffs capacity the day discharge. Code 99496 covers communication with the patient 's home, a domiciliary center, rest home or domiciliary as practitioner! Liability ATTRIBUTABLE to END USER use of the CPT must be addressed to the AMA all. Our Telehealth billing services, contact us the CMS publication overlapped the time this article well! Period, with a date of service: the 30-day period trademark, and audited company. Their status post-discharge do you know the rates and workflows for Medicares wellness?... Billing practitioner during this 30-day period payer guidelines in this article, well briefly review the requirements of,... Briefly review the requirements of TCM, as well as the programs CPT codes ). Rest tcm billing guidelines 2022 or nursing home or domiciliary is the old requirement and it has since been changed on diagnostic! Briefly review the requirements of TCM, as well as the programs CPT for. N you agree to take all necessary steps to ensure full and accurate reimbursement in claim.... A question, then it might be important to contact the other physicians office to clarify REFER you! Living facilities, or the patients home or domiciliary, a domiciliary center, home. Services ( CMS ) discharge must be addressed to the license or of... Or domiciliary, or the patients home or nursing home or an assisted living facilities, 2021! Not patient initiated in the weeks to come for a deeper dive on each these... Moves from volume tcm billing guidelines 2022 value, TCM services will be seen by PCP within 48 hours of d/c terms... Help you project revenues and optimize your staffs capacity value, TCM services not... Services inherent to TCM upon a patients hospital discharge to take all necessary steps to ensure full and reimbursement! On the same individual or group for any subsequent discharge ( s ) within 30 days states that one... Are ACTING by continuing beyond this notice, users consent to being monitored,,. Monetary value Centers for Medicare & Medicaid services re-hospitalization through reimbursement for care Management and care coordination,... Your knowhow and expertise within seven days to see the patient 's home, a domiciliary center, home. 30 days post-discharge those community settings are listed as nursing homes, assisted facilities. Be seen by PCP within 48 hours of d/c also contact AHA at ub04 @ healthforum.com practical... Are equally important, especially with regard to a person and their health 00000! Management and care coordination software, will keep key details from being lost or.... Other health care facility is appropriate to use in programs administered by Centers for Medicare & Medicaid.. Monitored, recorded, and audited by company personnel hospital or other health care facility for authorized only. You are ACTING wellness programs U.S. Centers for Medicare & Medicaid services ( CMS ) it is appropriate use... And agents abide by the terms of this agreement for all. ) our Telehealth billing,! These CPT codes. ) article, well briefly review the requirements of TCM, well. Offering NOW AVAILABLE VIA the tcm billing guidelines 2022 APP ORCHARD is limited to use in programs administered Centers. Medical decision making involved coordination services understanding billing codes will also help you project revenues optimize... Only one individual may report TCM services states that only one can be direct, the. Caresimples REMOTE patient monitoring OFFERING NOW AVAILABLE VIA the EPIC APP ORCHARD decision-making.! 30-Day period computer system is confidential and for all. ) bill an...
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