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Transcript of Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Kuehn Consulting, LLC Waukesha, WI 53186 (262) 574-1064 l...
![Page 1: Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Kuehn Consulting, LLC Waukesha, WI 53186 (262) 574-1064 l LKuehn1@wi.rr.com Cardiovascular Coding with ICD-10-PCS 1.](https://reader030.fdocuments.net/reader030/viewer/2022033022/56649d8e5503460f94a77106/html5/thumbnails/1.jpg)
Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA
Kuehn Consulting, LLC
Waukesha, WI 53186
(262) 574-1064 l [email protected]
Cardiovascular Coding with ICD-10-PCS
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![Page 2: Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Kuehn Consulting, LLC Waukesha, WI 53186 (262) 574-1064 l LKuehn1@wi.rr.com Cardiovascular Coding with ICD-10-PCS 1.](https://reader030.fdocuments.net/reader030/viewer/2022033022/56649d8e5503460f94a77106/html5/thumbnails/2.jpg)
2© Kuehn Consulting, LLC 2
Our Topics Today….Our Topics Today….
• What is ICD-10-PCS and how does it work?
• Root Operations commonly performed on cardiovascular structures– Definitions– Details
• Common endovascular procedures and their coding
![Page 3: Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Kuehn Consulting, LLC Waukesha, WI 53186 (262) 574-1064 l LKuehn1@wi.rr.com Cardiovascular Coding with ICD-10-PCS 1.](https://reader030.fdocuments.net/reader030/viewer/2022033022/56649d8e5503460f94a77106/html5/thumbnails/3.jpg)
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Procedure Code Structure
ICD-9-CM Procedures
ICD-10-PCS.33 99 22 99
00 44 11 LLKK 00 JJ
Fem-Pop Bypass with Gore-Tex Graft
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What is ICD-10-PCS?What is ICD-10-PCS?
• ICD-10 (international version) does not contain a procedure coding system
• CMS contracted to develop a new procedure coding system
• The new system is intended to replace ICD-9-CM Volume 3 for reporting inpatient procedures
• CPT and HCPCS will still be used where currently in place
![Page 5: Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Kuehn Consulting, LLC Waukesha, WI 53186 (262) 574-1064 l LKuehn1@wi.rr.com Cardiovascular Coding with ICD-10-PCS 1.](https://reader030.fdocuments.net/reader030/viewer/2022033022/56649d8e5503460f94a77106/html5/thumbnails/5.jpg)
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ICD-10-PCS Code StructureICD-10-PCS Code Structure
• Codes comprised of seven components, called characters
• Individual units for each character have a letter or number assigned as a “value”
• 34 possible values:– Digits 0-9– Letters A-H, J-N, and P-Z– No I or O
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11 22 33 44 55 66 77
Body System
Section Root Root OperationOperation
Body PartBody Part
Approach
Device
QualifierQualifier
ICD-10-PCS Code Structure
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ICD-10-PCS Coding ProcessICD-10-PCS Coding Process
• Analyze documentation• Apply definitions• Select Root Operation• Reference Alphabetic Index• Verify in PCS Table
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Analyze DocumentationAnalyze Documentation
Procedure: Right Femoro-Popliteal Above-the-Knee Bypass with Gore-Tex Graft
This patient had painful cramping in his calf, due to occlusion of his superficial femoral artery. Due to severe varicose veins, a prosthetic Gore-Tex graft was used for the conduit.
Procedure: After placement of an epidural catheter for spinal anesthesia, the patient was prepped and draped in the usual sterile fashion. An incision was made in the patient’s groin and the right femoral artery was exposed. An incision was approximately 2 cm about the patient’s knee joint to expose the popliteal artery. Gore-Tex graft length is approximated and tunneled between the two sites. The graft is sutured to the femoral artery for the proximal anastomosis and then sutured to the above knee popliteal artery for the distal anastomosis. Both wounds are closed.
Root Opera-
tion
Device
Approach
Origin
Destina-tion
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Alphabetic IndexAlphabetic Index
• Root Operations• Reference for:
– Body Parts– Devices
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PCS Table Excerpt - 041PCS Table Excerpt - 041
041K0JL Fem-Pop Bypass with Gore-Tex
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System Structure
• Medical and Surgical
• Obstetrics • Placement • Administration • Measurement and
Monitoring • Extracorporeal Assistance
and Performance • Extracorporeal Therapies • Osteopathic • Other Procedures
• Chiropractic
• Imaging
• Nuclear Medicine
• Radiation Oncology
• Physical Rehabilitation and Diagnostic Audiology • Mental Health • Substance Abuse Treatment
Body System
Body PartRoot
OperationSection Approach Device Qualifier
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Section Section
• Defines the general type of procedure
• Medical and Surgical Section begins with “0”
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Body SystemBody System• Body System or Anatomical Regions
• Examples:– Lower arteries
– Tendons
– Respiratory system
– Endocrine system
– Upper Joints
Body System
Body PartRoot
OperationSection Approach Device Qualifier
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Root OperationRoot Operation
• Distinct definitions• Intent of procedure• Key to coding
Body System
Body PartRoot
OperationSection Approach Device Qualifier
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Med-Surg Root Operations
Alteration Bypass ChangeControlCreationDestructionDetachmentDilationDivisionDrainage
ReleaseRemovalRepairReplacementRepositionResectionRestrictionRevisionSupplementTransferTransplantation
ExcisionExtirpationExtractionFragmentationFusionInsertionInspectionMapOcclusionReattachment
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Body Part Body Part• Anatomical Site of Procedure• Driven by documentation:
Body System
Body PartRoot
OperationSection Approach Device Qualifier
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Body Part Value Dependent on
Body System Value
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Index by Body PartIndex by Body Part
• It means that PCS:– Refers to the external
pudendal artery as the femoral artery, left or right
– Refers to the external pudendal vein as the greater saphenous vein, left or right
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Body System Vs Body Part
Body System Body Part
.
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ApproachApproach
• Technique used to reach the site of the procedure
• Approach values:– Open
– Percutaneous
– Percutaneous Endoscopic
– Via Natural or Artificial Opening
– Via Natural or Artificial Opening Endoscopic
– Via Natural or Artificial Opening with percutaneous endoscopic assistance
– ExternalBody
SystemBody Part
Root Operation
Section Approach Device Qualifier
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Through the SkinThrough the Skin
Open Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure
Example: Open CABGExample: Abdominal hysterectomy
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Through the SkinThrough the Skin
Percutaneous Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedureExample: LiposuctionExample: Needle biopsy of liver
Percutaneous endoscopic
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedureExample: Laparoscopic cholecystectomyExample: Arthroscopy
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Approach Decision Tree
Start Incision? OpenYes
No
Through Skin?
Through Scope?
Yes
No
YesPercutaneous Endoscopic
PercutaneousYes
No
Through Opening?
No
External
Through Scope?
WithPercutaneous Endoscopic Assistance?
Yes Via Natural or Artificial Opening
Endoscopic
Via Natural or Artificial Opening
with Percutaneous Endoscopic Assistance
No
No
Yes
Via Natural or Artificial Opening
©Kuehn Consulting, LLC
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Approaches
Open
Percutaneous
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Combined 0pen and Percutaneous
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Device Device
• Devices that remain after procedure – Monitoring device– Intraluminal– Synthetic– Autologous tissue– Nonautologous tissue
Body System
Body PartRoot
OperationSection Approach Device Qualifier
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Device Types
Artificial Sphincter Endobronchial valveInterbody Fusion
DeviceSpinal Stabilization Device;
Facet Replacement
Cardiac Lead Endotracheal airwayInternal Fixation
DeviceSpinal Stabilization Device; Interspinous Process Device
Cardiac Rhythm Related Device
External Fixation Device
Intramedullary Internal Fixation
Device
Spinal Stabilization Device; Pedicle-Based Device
Contraceptive Device
Extraluminal Device Liner Stimulator Generator
Contractility Modulation Device
Feeding Device Monitoring Device Stimulator Lead
DefibrillatorHearing Device, Bone Conduction
Pacemaker, Single or Dual
Tracheostomy device
Diaphragmatic pacemaker lead
Hearing Device, Cochlear Prosthesis
Radioactive ElementVascular Access Device,
Reservoir or Pump
Drainage Device Infusion device Spacer
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Qualifier Qualifier
• Additional attribute• Narrow application • Examples:
– Source of transplanted tissue– Diagnostic– Other additional data
Body System
Body PartRoot
OperationSection Approach Device Qualifier
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5 PCS Tables5 PCS Tables
• Heart and Great Vessels• Upper Arteries• Lower Arteries• Upper Veins• Lower Veins
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Axillo-Femoral BypassAxillo-Femoral Bypass
• Femoral Femoral component
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Excision
Definition: Cutting out or off, without replacement, A PORTION OF a body part
Uses sharp instrument such as scalpel, wire, scissors, bone saw, electrocautery tip
Explanation:
The qualifier Diagnostic is used to identify excision procedures that are biopsies.Examples:• Sigmoid polypectomy• Renal biopsy
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Resection
Definition:
Cutting out or off, without replacement, ALL of a body part
Examples:
• Total nephrectomy • Total lobectomy of lung
Note: Lobes of the lung are the complete body part. Body part is not always the same as entire organ.
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Destruction
Definition:
Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent.
Note: None of the body part is physically taken out. There is no tissue to be sent for pathology because the tissue is destroyed.
Examples:
• Fulguration of bleeder• Cautery of skin lesion• Cryocautery of lesion
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Case to CodeCase to Code
The surgeon harvests the left radial artery through an incision for use in another simultaneous procedure.
What root operation is this?
Excision
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03B Table Excerpt03B Table Excerpt
03BC0ZZ
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Surgeon Note:Surgeon Note:
• Linguistically, we often transpose resection and excision. I personally would probably dictate this as a resection whether or not this fits with your coding rules.
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ExtractionExtraction
• Definition: Pulling or stripping out or off all or a portion of a body part by the use of force
• Explanation: The qualifier Diagnostic is used to identify extraction procedures that are biopsies
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Root Operations – ExtractionRoot Operations – Extraction
• Classic examples:– Tooth extraction– Vein stripping
• More challenging examples:– Bone marrow or
endometrial biopsy – Removal of intraocular
lens without replacement by implant
– Non-excisional debridement of skin
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Extraction: Surgeon commentsExtraction: Surgeon comments
Stripping Stab Phlebectomy
Deep System Superficial system
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Extirpation
Definition:
Taking or cutting out solid matter from a body part
Explanation:The solid matter may be
an abnormal byproduct of a biological function or a foreign body. The solid matter may or may not have been previously broken into pieces. No appreciable amount of the body part is taken out.Examples: •Thrombectomy •Choledocholithotomy•Removal of retained, infected suture
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ExtirpationExtirpation
The objective is to remove solid material such as a foreign body, thrombus, or calculus from the body
part.NOTE:
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Carotid Endarterectomy
Sources: http://www.nhlbi.nih.gov/health/health-topics/topics/carend/ and http://www.mayoclinic.com/health/medical/IM01657
Root operation = Extirpation
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03C Table Excerpt03C Table Excerpt
Let’s code that last picture: Open endarterectomy of the right internal carotid artery
03CK0ZZ
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Root Operation GroupRoot Operation Group
• Procedures that alter the diameter/route/of a tubular body part– Restriction – Occlusion – Dilation – Bypass
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Tubular Body PartsTubular Body Parts
• Hollow structures that carry fluid or gas/air
• No openings – Circulatory and Lymphatic systems
• Opening at one end – Respiratory and nose, Genitourinary, ear canal
• Opening at both ends – GI system, including hepatobiliary tree
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RestrictionRestriction
• Definition: Partially closing the orifice or lumen of a tubular body part
• Explanation: The orifice can be a natural orifice or an artificially created orifice
• Classic examples:– Esophagogastric fundoplication
– Cervical cerclage
• More challenging example:– Clipping of cerebral aneurysm
– Placement of restrictive stent in lacrimal duct
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Restriction
Percutaneous Restriction (Coiling)
• Endovascular Coil placement
• Root operation = Restriction
• Device = Intraluminal device
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Surgeon Notes: Banding
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Endovascular “Repair”
Abdominal Aortic Aneurysm
• Intraluminal device
• Bifurcated prosthesis
• Root operation = Restriction
• Device = Intraluminal device
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Case to CodeCase to CodeThe surgeon performs a clipping of an unruptured aneurysm of the basilar artery via a craniotomy.
What root operation is this?
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03V Table03V Table
03VG0CZ
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OcclusionOcclusion
Definition:
Completely closing the orifice or lumen of a tubular body part
Explanation:The orifice can
be a natural orifice or an artificially created orifice.
Examples:
•Fallopian tube ligation•Embolization of vascular supply, intracranial meningioma•Ligation of inferior vena cava
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OcclusionOcclusion
• The root operation Occlusion is coded when the objective of the procedure is to close off a tubular body part or orifice.
• Occlusion includes both intraluminal and extraluminal methods of closing off the body part.
• Division of the tubular body part prior to closing it is an integral part of the Occlusion procedure.
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Surgeon Notes Restriction vs. Occlusion for embolization
Surgeon Notes Restriction vs. Occlusion for embolization
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Endovenous Laser TreatmentEndovenous Laser Treatment
Through a tiny incision at the knee, a small tube is placed into the greater saphenous vein. Then, a laser or radiofrequency fiber is passed through the tube into the vein. Once in place, the fiber is activated, delivering very localized heat to the vein wall. In response, the vein closes down and becomes permanently blocked.
Source: http://www.ohsu.edu/dotter/venous_ablation.htm
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06L Table
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Dilation
Definition:
Expanding an orifice or the lumen of a tubular body part
Explanation:The orifice can be a
natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part.
Examples:•Percutaneous transluminal angioplasty with or without stent•Pyloromyotomy
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Coronary Sites Treated
Coding Note: In ICD-10-PCS, the classification of the coronary arteries is as a single body part. It doesn’t matter what the number of arteries treated is (i.e., right coronary artery, left anterior descending, or left circumflex, or the branches). The distinguishing factor is the number of sites treated.
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Percutaneous Transluminal
Coronary Angioplasty (PTCA) and Stenting
Percutaneous Transluminal
Coronary Angioplasty (PTCA) and Stenting
Therapeutic procedure used to treat the stenotic (narrowed) coronary arteries found in coronary heart disease.
Root Operation = Dilation
Device = Various types of intraluminal devices
Source: http://www.infobarrel.com/Risk_factors_and_the_management_of_Angina
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Different Devices?Different Devices?
• What if different devices are used on different sites?
• ICD-10-PCS Guidelines tell us:– Anytime a body part, approach, device
or qualifier is different, separate codes are assigned
– Dilate two unique body part values = two codes
– Dilate two sites of a body part using different devices = two codes
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Case to CodeCase to Code
The cardiologist stents two sites, proximal and mid, of the left anterior descending artery with CYPHER drug-eluting stents.
What root operation is this?
Dilation
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027 Table027 Table
027134Z
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BypassBypass
• Definition: Altering the route of passage of the contents of a tubular body part
• Explanation: Rerouting contents around an area of a body part to another distal (downstream) area in the normal route; rerouting the contents to another different but similar route and body part; or to an abnormal route and another dissimilar body part. It includes one or more concurrent anastomoses with or without the use of a device such as autografts, tissue substitutes and synthetic substitutes
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BypassBypass
• Classic examples:– Coronary artery bypass– AV fistula or graft creation
Type of Tissue
Device Characte
r
Definition
Autologous (vein or artery)
9 or A Referring to a graft in which the donor & recipient areas are in the same individual
Synthetic Substitute
J Any type of synthetic substitute
Nonautologous Tissue Substitute
K Nonautologous allogeneic donor tissue implanted from one human to another
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Coronary Artery Bypass Grafting
• CABG (Bypass)• Free Vein Graft:
– Greater Saphenous Vein
• Free Artery Grafts:– Right Internal Mammary
– Radial Artery
• Pedicle Artery Graft:– Left Internal Mammary
artery
Source: http://www.hakeem-sy.com/main/node/25417
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Non-Coronary
Downstream route
Coronary ArteryBody Part Qualifier
FROM TO
Body Part Qualifier
NUMBER OF SITES
FROM
Bypass
Coronary Sites
Reminder: The excision of the autograft is
coded as a separate procedure. (Guideline B3.9)
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Axillo-Femoral BypassAxillo-Femoral Bypass
• Femoral Femoral component
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Axillo-Femoral BypassAxillo-Femoral Bypass
Synthetic substitute used to create bypass
Right axillary artery to upper leg artery, right = 03150J6
Right axillary artery to upper leg artery, bilateral = 03150J8
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Case to CodeCase to CodeProcedure: CABG
Description of Procedure: The chest was opened through a median sternotomy incision. The pericardium was opened. Cardiopulmonary bypass was initiated. The greater saphenous vein was harvested via incision from the left lower extremity. The patient was cooled and cross-clamped. The cold blood cardioplegia solution was administered. Individual segments of saphenous vein were sewn to the obtuse marginal, to the posterolateral branch of the circumflex artery, and to the distal right coronary artery respectively. Each of these anastomoses were carried out with running sutures of 7-0 Prolene.
At the termination of this, warm blood cardioplegia was administered and the aortic cross-clamp was then released. A partial occluding clamp was placed on the aorta. Three buttons of aortic tissue were excised and used as three proximal anastomoses for the saphenous grafts which were carried out with running sutures of 6-0 Prolene. With the patient fully re-warmed, the heart resumed a good contractility and resumed a normal sinus rhythm. The patient was weaned from cardiopulmonary bypass. The chest was closed in layers in the usual fashion and dry sterile dressing was applied.
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CABGCABG
How many procedures must be coded?
Three
What are the root operations?
Bypass
Excision
Performance
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AnswersAnswers
021209W, 06BQ0ZZ, 5A1221Z
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InsertionDefinition:
Putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part
Examples:
• Insertion of:
–radioactive implant
–central venous catheter
–Pacemaker
Note: Index states “Insertion of device in….” to remind you that this always involves a device
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InsertionInsertion
The root operation Insertion represents those procedures where the sole objective is to put in a device without doing anything else to a body part. Procedures typical of those coded to Insertion include putting in a vascular catheter, a pacemaker lead, or a tissue expander.
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Perm-A-CathPerm-A-Cath
Central Venous Catheter (Infusion Device)
Insertion, Heart and great vessels, infusion device
Code body part as where catheter stops
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Reservoir and PumpReservoir and Pump
Implantable VAD Reservoir
Implantable VAD Reservoir and Pump
Insertion, SubQ,Vascular access device
Insertion, SubQ,Infusion device, pump
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PacemakerPacemaker
• Medical device that delivers electrical impulses to the heart muscles using electrodes
• Regulates the beating of the heart
• Maintains an adequate heart rate when:– Heart too slow– Block in conduction
mechanism
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DefibrillatorDefibrillator
• An implantable cardioverter-defibrillator (ICD) is a small battery-powered electrical impulse generator:– Patient at risk for sudden
cardiac death due to:• Ventricular fibrillation• Ventricular tachycardia
• Programmed to detect cardiac arrhythmia and correct it by delivering a jolt of electricity
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RemovalRemoval
• Definition: Taking out or off a device from a body part
• Explanation: The procedure for taking out the device is coded to the root operation Removal and the procedure for putting in the new device is coded to the root operation performed.
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RemovalRemoval
• Classic examples:– Drainage tube removal – Cardiac pacemaker removal
• More challenging examples:– Removal of infected surgical mesh, or
neurostimulator lead
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Case to CodeCase to Code
PROCEDURE: Pacemaker generator replacement.
PROCEDURE IN DETAIL: With the patient under monitored anesthesia care, the patient's left upper chest and neck were sterilely prepped. The previous pacemaker scar was incised. The subcutaneous tissues were divided with electrocautery. The fibrous capsule was opened and the pacemaker explanted. The lead was loosened and removed from the pacemaker generator and quickly attached to the pacemaker cable for pacing and testing, as the patient is pacemaker dependent. Pacing parameters were excellent. The lead was then inserted into the receptacle of the pacemaker generator and tightened down.
The pocket was irrigated with antibiotic solution. Hemostasis was good. The generator was inserted into the pocket. The incision was closed in layers with continuous Vicryl sutures including the subcuticular layer.
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PacemakerPacemaker
How many procedures are there?
Two
What are the root operations?
1.Removal (of device from…)
2.Insertion
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0JP Table0JP Table
0JPT0PZ
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0JH Table0JH Table
0JH604ZLeads are not changed – if done, additional code(s)
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ReplacementReplacement
• If the body part has been previously replaced, a separate Removal procedure is coded for taking out the device used in the previous replacement
• Classic examples:– Total hip replacement, – Bone graft or free skin graft
• More challenging examples:– Corneal transplant from donor– Mitral valve replacement, porcine valve
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Cardiac Valve ReplacementCardiac Valve Replacement
• Biologic vs. Mechanical Replacement– Aortic Valve– Tricuspid Valve– Mitral Valve
• Root Operation = Replacement
• Device = Synthetic or Zooplastic
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SupplementSupplement
• Definition: Putting in or on biological or synthetic material that physically reinforces or augments the function of a body part
• Explanation: The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously replaced. If the body part has been previously replaced, the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part
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SupplementSupplement
• Classic examples:
– Herniorrhaphy using mesh
– Free nerve graft– Mitral valve ring
annuloplasty
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Atrial Septal Defect Closure
• Catheter Based:– Femoral vein– Double “Umbrella”
Closure device
• Open surgical approach:– Dacron Patch
• Root operation = Supplement
• Device = SyntheticSource: http://www.scubamed.com/PFO_page.html
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Case to CodeCase to Code
The surgeon performs open heart surgery to repair an atrial septal defect with mesh. What root operation is this?
Supplement
Which body part value will we pick?
Atrial septum
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02U Table02U Table
02U50JZ
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Supplement ExamplesSupplement Examples
Wrapping, whether inside or outside the vessel, is
Supplement
Not a stent
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Surgeon Note:Surgeon Note:
• I have trouble with this.• We don’t call this supplementation,
and don’t conceive of it this way. This is an aneurysm exclusion or and aneurysm replacement in our language
• The wrapping is for convenience really and other more subtle functions. It is NOT the purpose of this operation.
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Repair
Definition:
Restoring, to the extent possible, a body part to its normal anatomic structure and function
Explanation:
Used only when the method to accomplish the repair is not one of the other root operations
Examples:•Suture of VSD•Suture of laceration
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Cardiac Valve Repair
• Repair–Using sutures
• Root operation = Repair
Source: http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.php
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Repair Decision Tree
Procedure performed to restore body part
Yes
Code Repair
No
Code Supplement
Body part remains in
place?
Yes
Code root operation
performed, such as Replacement
No
Body part reinforced with
device?
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Name That Root!
• Endovascular laser treatment– Occlusion
• Clamping of artery for patient with aneurysm– Restriction
• Suture of laceration of artery– Repair
• Heart valve annuloplasty
– Supplement
• Angioplasty for plaque
– Dilation
• Pacemaker placement
– Insertion
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Review QuestionsReview Questions
A patient has a PTCA of two sites of the LAD utilizing one drug-eluting stent and one bare metal stent. How many codes are assigned?
A.OneB.TwoC.Need additional information
Answer: B. Two
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Review QuestionsReview Questions
In CABG procedures, the 4th character (body part) indicates:
A.The location that the blood is flowing “from”B.The number of sites treatedC.Need additional information
Answer: B. The body part indicates the number of sites treated.
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Review QuestionsReview Questions
In pacemaker insertion procedures, the pacemaker is inserted into the:
A.Chest wallB.Subcutaneous tissue of the chestC.HeartD.Atrium or Ventricle
Answer: B. Subcutaneous tissue of the chest
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Thank you!
Contact Information:
Lynn Kuehn, MS, RHIA, CCS-P, FAHIMAKuehn Consulting, LLC
1155 S. Springdale Road Waukesha, WI 53186
O: 262-574-1064
F: 262-574-0828
[email protected] www.KuehnConsulting.com