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02/27/2010    

CODINGLINE CORNER

Query: Billing Lapidus/Akin


The doctor performed a Lapidus-type bunionectomy (CPT 28297) and an Akin-type osteotomy (CPT 28310) on a patient. CPT 28310 was denied as inclusive to the Lapidus-type procedure. Does anyone have any suggestions on how I should have billed the procedures? Or how I should appeal the denial?


Sarah Avilleira, Office of Peter A. Wishnie, DPM, Piscataway, NJ


Response: The correct billing for a Lapidus-type bunionectomy and an Akin-type osteotomy is:


#1 CPT 28297 (correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus type procedure); and CPT 28310-59 (osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe). or


#2 CPT 28740 (arthrodesis, midtarsal or tarsometatarsal, single joint); and CPT 28298-59 (correction, hallux valgus (bunion), with or without sesamoidectomy; by phalangeal osteotomy).


Both coding methods are correct. By the way, the value of coding example #2 is higher than #1. The payer was incorrect in denying CPT 28310 as inclusive (unless you did not add a "-59" modifier to the code). I recommend you appeal with submission of a corrected claim with either one of the coding examples listed above.


It should be noted that CPT 28310 is a designated "separate procedure" code. Separate procedure means that in order to be independently reimbursed, the procedure must not be an integral part of a comprehensive procedure being billed. CPT 28310 needs to be distinct, and in coding example #1, it is.


Harry Goldsmith, DPM, Cerritos, CA


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04/25/2015    

CODINGLINE CORNER


Query: Arthroereisis Coding


 


What is the best current billing code for subtalar arthroereisis? 


 


Louis Cappa, DPM, New Windsor, NY


 


Response: Most carriers still don't recognize any code for this. I suggest billing CPT 28899 (unlisted procedure) and also sending an op report, along with a letter noting a CPT code that you feel is comparable to the work that was done for this surgery. 


 


Jeffrey Lehrman, DPM, Springfield, PA 


 



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04/22/2015    

CODINGLINE CORNER


Query: Screw Removal and Replacement


 


My patient walked extensively on her foot after an Austin/Akin-type bunionectomy performed with screw fixation. This resulted in the distal screw moving considerably. I will be taking her back to the operating room to remove the screw from the hallux and replace it with a staple. How would I code this? Since I already created the osteotomy and billed for it the first time, all I am doing is re-fixating the same osteotomy, so it seems counter-intuitive to bill the Akin again with a "-78" modifier. 


 


Wendy Siegel, DPM, Smithtown, NY


 


Response: Basically, the surgery involves removal of one fixation device for another at the same anatomical location. I recommend billing CPT 20680 (removal buried pin, screw, plate, etc.; deep). I don't think you should bill for replacing with a staple since you already were compensated once for that when you billed the original surgery. 


 


Howard Zlotoff, DPM, Camp Hill, PA



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04/17/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Ron Freireich, DPM


 


Thank you, Dr. Lehrman! I now know there is at least one other physician in this country who gets it. Not only shame on HHS, but shame on the leaders (whoever they are) of our medical system for allowing this to go on un-checked. Who plays a game when the people making the rules change the rules in the middle of the game? You can’t possibly win. It is a disgrace. The game should be stopped and all players involved come to an agreement on what is reasonable, manageable, and good for the patient. The current system is not.


 


Once again the government is reforming a system because they couldn’t get it right the first time. I understand this change might ease the burden this year, but what about next year and the year after. This system is a failure and the people making these rules are failing us and our patients.


 


Ron Freireich, DPM, Cleveland, OH

04/15/2015    

CODINGLINE CORNER


Query: Stage II MU Attestation


 


Does anyone know if the 90-day attestation (annual quarter) for Stage II meaningful use is in effect, or will it be for an entire year as was required for 2015 calendar year? 


 


Joseph Borreggine, DPM, Charleston, IL


 


Response: On April 10, 2015, CMS issued a new proposed rule for the EHR incentive program. Part of the proposed rule includes a 90-day reporting period for 2015. 


 


The other big news in this announcement is that CMS is proposing that the number of patients in a physician's practice who must access their records electronically be lowered from 5% of all patients to just 1 single patient for stage 2. The proposed changes are subject to a 60-day comment period and a final rule will evidently be drafted after that. 


 


My unsolicited opinion:  Regardless of how you feel about the content of the announcement, it is shameful that this comes out on April 10, 2015. MEMO TO HHS: 2015 started over 3 months ago! We're not going to find out what we actually have to do for 2015 until over HALF of the year is over. What a disgrace. Shame on you, HHS. Finally, nice job burying this by announcing late on a Friday afternoon. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 



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04/11/2015    

CODINGLINE CORNER


Query: Registering Intent for Public Health Measure


 


Should my office be registering my intent for any specialized registry submission? My folks and I are not aware of any, however, I wanted to ensure that we are complying with Meaningful Use. My practice has already registered for the Cancer Registry. We are exempt from the Immunization Registry. And, in Pennsylvania (according to our EMR), we are able to claim an exemption for the Syndromic Surveillance Measure due to cost. 


 


Gary Raymond, DPM, Altoona, PA


 


Response: You must register for: 


- Immunization Registries 


- Syndromic Surveillance Registries 


- Cancer Registries 


 


To register, contact your State Department of Health. You do not have to register for a specialty registry at this point in time. 


 


Michael L. Brody, DPM, Commack, NY



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04/08/2015    

CODINGLINE CORNER


Query: Excision of Mass Coding


 


How do I code for an "excision of soft tissue mass, foot" when the path report states it is a capillary hemangioma? 


 


Jane Koch, DPM, Evansville, IN


 


Response: Consider using one of these codes, based on anatomic location, depth of mass: 


 


CPT 28043 - excision tumor, foot, subcutaneous tissue 


CPT 28045 - deep, subfascial, intramuscular 


 


Howard Zlotoff, DPM, Camp Hill, PA 


 



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04/04/2015    

CODINGLINE CORNER


Query: Two Sets of X-Rays Done Same Day


 


A patient had two sets of x-ray studies done in the same visit. The second one was done post-reduction of a dislocated joint. How can I bill the second set of x-rays? 


 


Kelly Malinoski, DPM, Naples, FL


 


Response: Append a "-76" modifier on the second x-ray study. This modifier is used when there is a repeat procedure by the same physician. The "-59" modifier would be inappropriate to apply to the second x-ray code. 


 


Tony Poggio, DPM, Alameda, CA


 



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04/01/2015    

CODINGLINE CORNER


Query: Ultrasound-Guided Injection Code


 


Can someone please tell me the correct code for ultrasound-guided injections for plantar fasciitis?  


 


Kenneth T. Goldstein, DPM, Williamsville, NY


 


Response: CPT 76942 - Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation 


 


Your documentation would have to clearly note why you required (i.e., the medical necessity for) ultrasound guidance to administer what is a commonly performed infiltrative injection around the plantar fascia. Additionally, be prepared to offer peer-to-peer published studies that back the medical necessity for imaging to significantly impact therapeutic improvement of the injection over not using imaging to place your needle. 


 


Tony Poggio, DPM, Alameda, CA 


 



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03/31/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Michael M. Rosenblatt, DPM


 


Sometimes, "high risk" routine foot care treatment is also "high risk" for the podiatrist. Daniel C Albertson, APRN wrote a coding/treatment question for a high-risk patient in an extended care facility who had no obvious care by a medical doctor. The concern was for proper coding of RFC in the absence of a treatment plan. 


 


This situation goes considerably beyond coding and Medicare. Whenever there is a bad result, say an amputation after podiatric care, family members and other providers tend to look at the (recent) DPM care as primarily responsible for ...


 


Editor's note: Dr. Rosenblatt's extended-length letter can be read here.

03/28/2015    

CODINGLINE CORNER


Query: No PCP with High Risk Foot Care Patient


 


A doctor in our office recently evaluated and treated a patient at an assisted living facility for high risk foot care. The patient qualified for palliative services with absent pedal pulses and pain. The patient reported not having a primary care provider and has not seen one in over 3 years. I believe that we are required to indicate an active treatment plan to Medicare (by submitting last date of visit to a primary care physician) when treating for high risk foot care. Is this correct? How would we handle this case, as the patient has not been treated for such a long period of time and states that he is not under a primary care provider's care? 


 


Daniel C Albertson, APRN; President, Office of Paul Krestik, DPM,  London, KY


 


Response: Most routine foot care LCDs require that you submit the date the patient was last seen, NPI number, and the name of the MD/DO managing the patient's systemic condition, IF the qualifying diagnosis has an asterisk (*) next to it. Peripheral vascular disease conditions, with few exceptions, have no asterisk designation. I don't think you have to worry about it in the case you describe. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 



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03/25/2015    

CODINGLINE CORNER


Query: Proper Place of Service Code


 


We provide podiatric services to mentally and physically disabled patients at a sheltered workshop and an activity meeting place. We have seen some indications that you cannot use the place of service code "11" (office) for these places. I have contacted Medicare previously and they could not answer our question. What is the correct place of service code for billing? 


 


Linda Stevens, Office Assistant, Office of Jeff Chism, DPM, Merrill, WI


 


Response: Place of service 99. 


 


Unless you're paying rent, etc. for the use of the space you're using to see these individuals, it cannot be considered an office. Since the type of location where the services are rendered is not one currently defined, POS 99 is the correct code to report. 


 


Joan Gilhooly, CPC, CPCO, Lebanon, OH


 



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03/21/2015    

CODINGLINE CORNER


Query:  Nail Avulsion with Nail Bed Repair


 


Does anyone have a code and diagnosis for total avulsion with nail bed repair? 


 


Craig Sapenoff, DPM, West Palm Beach, FL


 


Response: The code you are looking for is CPT 11760 (repair of nail bed). The avulsion on the nail would be "incident to" the repair procedure and not separately billable. 


 


The diagnosis most probably would be ICD-9 892.0 (open wound of toe), but other diagnoses might be used if there are other issues that you did not mention in the nail bed laceration . 


 


Paul Kinberg, DPM, Dallas, TX 


 



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03/18/2015    

CODINGLINE CORNER


Query: Routine Foot Care Coding Scenario


 


The patient presented with 3 thickened, mycotic, dystrophic, and elongated nails. The other 7 nails are normal (only elongated). The treatment consisted of debridement of 2 of the thickened (mycotic) nails and trimming of the other nails. Assuming they meet "Q8" vascular risk, would this be coded: CPT 11720-Q8 G0127-Q8-59 or CPT 11719.-Q8 CPT 11720-Q8-59? 


 


Barry Feinstein, DPM, North Hollywood, CA 


 


Response: The coding in both sets is "correct" regarding use of modifiers. 


 


The selection of option 1 versus 2 depends on the description of the nails. If the nails not debrided are "normal", but long and in need a trim, then option 2 is correct. 


 


If the nails not debrided are "dystrophic" (but not thick requiring debridement), and long in need of a trim, then option 1 is correct. 


 


Tony Poggio, DPM, Alameda, CA 


 



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03/14/2015    

CODINGLINE CORNER


Query: Long-Term Care Coding


 


We see patients at a long-term care facility - the rehabilitation institute (place of service, 61), that is associated with a hospital. Patients are inpatient, recovering from different conditions. 


What E/M codes should we use for a new/established patient? Also, recently, our biller told us that CPT 11042 and CPT 10061 are not being paid when performed at this facility. The reason code was N428 (not covered when performed at this place of service). My question is why? If these codes aren't acceptable at that type of facility, what else could we use? 


 


Pam Eernisse, DPM, Chicago, IL


 


Response: I would change the place of service to either "31" or "32". If you check the description, it's actually more appropriate because your patient will recover. POS 61 is for patients with physical disabilities. 


 


POS 32 - A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. 


 


POS 61 - A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services. 


 


Both codes are probably applicable to the facility, however you want to get paid. Just use "31" (skilled nursing) or "32" (nursing). I've always found the description odd because, of course, nursing home patients are still under the supervision of a physician. E/M codes for new patients are CPT 99304-99306, for established patients are CPT 99307-99310.


 


Lisa Merkow, CPC, Largo, FL


 



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03/11/2015    

CODINGLINE CORNER


Query: Ultrasound-Guided Injection


 


Would the following dictation warrant the “medical necessity” for an ultrasound guided injection? “Ultrasound guided injection was utilized today to avoid infiltration into the fat pad, which could cause a thinning of the pad and additional complications.” If this wording does not appear to justify the use of ultrasound, can someone provide a few acceptable examples? 


 


Kelly Bruce, Kingston, NY


 


Response: You are correct that this issue was discussed before, and unfortunately, the clarification that you seek does not exist. It also appears by your second question that your office is seeking a set of "magic words" that will validate this procedure as medically necessary. Your question can only be answered with opinions; the same opinions that have already been offered. Some payers issue written statements in LCDs and medical policies regarding medical necessity of certain procedures. To me, it sounds like the routine use of the wording offered does not justify medical necessity; it offers 'billing justification necessity.' 


 


Richard Rettig, DPM, Philadelphia, PA 


 



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03/09/2015    

CODINGLINE CORNER


Query: Post Office Box Break-In


 


My medical office post office box was broken into. I have no idea if any mail was stolen or not. I just found out about it today when our key would not open the box. What, if any, obligations do I have under HIPAA? 


 


Name Withheld by Moderator


 


Response: Your obligation under HIPAA is to do a careful investigation to determine if any patient information was compromised. If you determine that no health information was compromised, document that fact and you are done. If you find the contrary to be true, you will need to follow the rules on breach notification for the affected patients. The details for doing this are too extensive for this post, but I recommend that you consult with a healthcare attorney. You want to make sure you respond properly to this event so that you neither over-react or under-react. And don't wait-- you generally have 30 days to do breach notifications. 


 


J. Kevin West, Esq, Parsons Behle & Latimer, Boise, ID 


 



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03/04/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Jack Ressler, DPM


 


I can't tell you the countless number of times this has happened in our office. The major problem arises when we tell our patients to call Medicare to verify. 90% of the time Medicare tells the patient erroneously to just have your doctor re-submit the claim. 


 


Jack Ressler, DPM, Tamarac, FL 

03/04/2015    

CODINGLINE CORNER


Query: Follow-up Hospital Consults


 


Can a specialist continue to bill for follow-up E/M visits to a hospitalized patient, whether or not any procedure was performed? Would these be CPT 9923x? I've heard that a specialist may only have one E/M charge per admission. 


 


James Hatfield, DPM, Encinitas, CA


 


Response: You absolutely may bill for follow-up E/M visits as long as the visit is not during the global period for a related procedure you performed. There are no other limits. Bill it at the appropriate level, of course. 


 


Richard Papperman, MBA, CHBME, Cape May Court House, NJ 


 



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02/28/2015    

CODINGLINE CORNER


Query: Modifier -25 vs -57 Use


 


If you have a new patient who presents with pain in a toe, you examine the patient to find out he/she has a paronychia. You decide to perform a nail surgery at the same time of the initial visit. Should one use new office visit with modifier "-25" or "-57" with pain in foot as the diagnosis and then CPT 11730 or CPT 11750 with the paronychia diagnosis along with the location? This question comes up in order to determine if the insurance company will pay for the initial visit in addition to the surgery. 


 


David Hamilos, DPM, Johnson City, TN


 


Response: These modifiers both alert the payer that the E/M service performed was significant and separately identifiable and not included in the surgical service allowance. The distinction between these two modifiers is that the "-25" modifier is used to amend the E/M code only when the surgical procedure has a 0 or 10 day global. The "-57" modifier is used to amend the E/M code when the surgical procedure has a 90-day global and a decision for surgery was made through the E/M service for a procedure that will be performed within 24 hours. 


 


Paul Kesselman, DPM, Woodside, NY


 



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02/26/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B



From: Michael M. Rosenblatt, DPM


 


I must respectfully disagree with Dr. Richard Rettig, regarding his advice to a DPM who was "saddled" with a Medicare deductible because an internist waited to turn in his billing, but directly billed the patient, who (allegedly) paid at time of that treatment. (Dr. Rettig suggested that the DPM contact the MD to "work out" the payment issue.) 



 


This is actually a fairly common occurrence. Most physicians wait to turn in their Medicare billings, hoping that someone else will absorb the deductible. So, even if you wait, there is still a good chance that...


 


Editor's note: Dr. Rosenblatt's extended-length letter can be read here. 


02/25/2015    

CODINGLINE CORNER


Query: Patients and Medicare Deductibles


 


A new patient was evaluated and treated for plantar fasciitis. She informed my front office that she had gone to her internist 10 days before and paid him $147 dollars, meeting her annual Medicare deductible. I billed Medicare for a new patient visit and a strapping. About one week later, I got an EOB from Medicare stating that the patient did not meet her deductible and is responsible for $105. She has no Medicare supplement. Obviously, the internist did not submit his claim until after I did, so I got stuck being owed the deductible. My question is, how do other offices handle this situation? Any advice would be greatly appreciated. 


 


Ronald Oberman, DPM, Deerfield Beach, FL


 


Response: One solution is to call the internists office, explain the situation, and try to work it out either between you two, or facilitating the overcharge refund to the patient, then getting it from the patient. That is the cleanest way to patch this up. 


 


A second way is to have the patient call 1-800-Medicare in your office, and clearing it up with your input if necessary. Since you say you have a lot of problems with this, then I suggest that you avoid this in the future, either for specific patients or across the board, by holding your claims until other doctors eat the deductible for you. 


 


Richard Rettig, DPM, Philadelphia, PA 


 



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02/21/2015    

CODINGLINE CORNER


RE: Billing CPT 96372 By a Podiatrist


 


Are there any circumstances/medications etc. when a podiatrist can bill for CPT 96372 (therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). If so, what would be the circumstances (i.e., when would it be appropriate, what medications, etc.)? Is it allowable by Medicare and/or commercial payers to bill the code in addition to other CPT injection codes or, conversely, when the code not be billed with/bundled to other injection codes or medications? 


 


Terry Boykoff, DPM, Santa Monica, CA


 


Response: I don't know of any podiatrists who administer IM injections of antibiotics within their offices. However, I could easily foresee injection of tetanus toxoid or antitoxin as long as it is within the state scope of practice. You can bill any payer for the injection administration, as well as the therapeutic supply 


 


Rick Horsman, DPM, Olympia, WA 


 



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02/18/2015    

CODINGLINE CORNER


Query: PQRS #317: Screening for High Blood Pressure


 


Patients 18 years and older are considered "not eligible" for this measure if they have an active diagnosis of hypertension. So, if a patient has a diagnosis of hypertension AND has a pre-hypertensive or hypertensive blood pressure reading (systolic > or = 120 OR diastolic > or = 80) at their visit, they would be coded as G8951 ("pre-hypertensive or hypertensive blood pressure reading documented, indicated follow-up NOT documented, patient NOT eligible"). But if the patient has a diagnosis of hypertension and their blood pressure is controlled on medication resulting in a normal blood pressure (systolic <120 AND diastolic <80), which code would be used: G8783: "Normal blood pressure reading documented, follow-up NOT required" or G8784: "Blood pressure reading NOT documented, patient NOT eligible"? 


 


Nancy Hayata, DPM, Huntington Beach, CA


 


Response: If a patient has an active diagnosis of hypertension, you report the G8784 no matter what their blood pressure reading is when taken. Technically, you do not have to take their blood pressure since this is a screening for high blood pressure measure, but for good medical care, it makes sense to take their blood pressure if they have an active diagnosis of hypertension and advise them to follow up with the provider treating their blood pressure if it is elevated. Either way, you report G8784 and this is excluded from calculating your performance on the measure but meets the reporting requirement. 


 


Jim Christina, DPM, Bethesda, MD 


 



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02/14/2015    

CODINGLINE CORNER


Query: CAM Walker and Night Splint Coding


 


Our DME vendor tells us that the “new” HCPCS code we should use for CAM walking boots is L4361, and L4397 for night splints. These new codes describe pre-fabricated devices with minimal adjustments. The codes we previously used were L4360 for CAM walking boots and L4396 for night splints. These are now described as “pre-fabricated devices that require substantial modification by a certified orthotist or an individual with equivalent expertise.” We are looking for feedback from others as to how they are now billing for these DME products. 


 


Kelly Bruce, Kingston, NY


 


Response: In 2014, CMS initiated many HCPCS changes which, as usual, created lots of confusion for orthotics and prosthetic providers. Instead of adding new codes with new definitions, CMS created new HCPCS codes using the existing definitions and also provided new definitions to existing codes. The key to your (and others' queries on this) is to look at the last portion of the definition and decide: 


 


1) What CMS meant by substantial modification and did you do so? 


2) Are you an individual with the expertise required to make the substantial modification? 


 


A DPM should be able to meet the qualifications to substantially modify (devices). And one would need to document what was done and why an OTS (off-the-shelf) device was inappropriate. "Substantially modify" is not implied by simply adjusting a strap or adding a Velcro pad from a package to the strap or boot. The new codes are appropriate for most CAM boots and night braces


 


Paul Kesselman, DPM, Woodside, NY 


 



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02/11/2015    

CODINGLINE CORNER


Query: Digital Block for Corn Debridement


 


A patient presented to the office with a painful dorsolateral corn on her right 5th digit. I attempted to debride it, however, it was so tender, she required a digital block prior to debridement. I was considering using CPT 64450 (injection anesthetic agent, other peripheral nerve or branch), but when reviewing the Medicare LCD, I didn't find an appropriate ICD-9 code to justify the injection. 


 


Jay Seidel, DPM, Baltimore, MD


 


Response: Performance of a procedure (e.g., CPT 11055) that usually does not require local anesthesia in rare cases, like you stated, may require administration of local anesthesia. In those relatively rare cases, the anesthesia would be included in the procedure. I do not recommend billing the injection as CPT 64450. 


 


David J. Freedman, DPM, CPC, Silver Spring, MD 


 



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