inpatient rehabilitation facility reimbursement and icd-10-cm · • the icd-10-cm official...
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Inpatient Rehabilitation Facility Reimbursement
and ICD-10-CM
James S. Kennedy, MD, CCS
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Goals
• Describe ICD-10’s Impact on Inpatient Rehabilitation Facility’s (IRF’s) revenue cycle
• Develop strategies that maintain the integrity of ICD-10-based documentation and coding in the ICD-10 environment
2
Goals • Identify what is new or different in ICD-10-CM/PCS as
compared with ICD-9-CM, emphasizing its impact on • Physician and facility quality and cost-efficiency
measurement • Physician knowledge and work-flow • Physician office and hospital revenue cycles
• Review clinical aspects of the ICD-10-CM/PCS classification and terminology
• Outline St. Joseph’s ICD-10 strategy and plans for engaging the medical staff in ICD-10 documentation and coding integrity
ICD-10 Implementation Date Tentatively on October 1, 2015
Diagnoses Procedures ICD-10-CM
(Clinical Modification) Used by all entities: (providers & facilities) for diagnoses To be used in all settings: – Hospital inpatients – Hospital outpatients – Physicians offices – Emergency department – Home health – Long-term care – Rehabilitation facilities
ICD-10-PCS (Procedure Coding System)
Used by inpatient facilities ONLY • Includes outpatient facility services
rendered within the prior 72 hours of writing the inpatient order
• Very different than ICD-9-CM or CPT
CPT • Physician and outpatient/observation
facility services still utilize CPT • CPT does not change!!
International Classification of Disease Versions
• First edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893
• WHO took in 1948 when the Sixth Revision, which included causes of morbidity for the first time, was published. • 1977 - ICD-9
• 1993 - ICD-10
• 2017 (tentative) - ICD-11
US Modifications – ICD-10-CM & PCS The Cooperating Parties
• CDC • Responsible for diagnoses
• CMS • Responsible for inpatient
procedures
• American Hospital Assn. • Responsible for interpreting
ICD-9 or ICD-10 (Coding Clinic)
• American HIM Assn. • Provides input from coding
community
ICD-10 Basics
• ICD-10-CM/PCS (and ICD-9-CM) are NOT clinical languages (like SNOMED) • ICD-9 and ICD-10 are useful for classifying healthcare
data for administrative purposes, including reimbursement claims, health statistics, and other uses where data aggregation is advantageous
• ICD-10-CM/PCS is based ONLY on provider documentation of clinical language, not on a patient’s clinical characteristics • The provider must use the magic words that drive ICD-
10-CM/PCS code assignment
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Overall Changes
• 34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system
• 17,045 (25%) of all ICD-10-CM codes are related to fractures
• 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’
• ~25,000 (36%) of all ICD-10 codes to distinguish ‘right’ vs. ‘left’
Cerebrovascular Diseases
• Cerebrovascular diseases (I60-I69) • Use additional code to identify presence of:
• alcohol abuse and dependence (F10.-)
• exposure to environmental tobacco smoke (Z77.22)
• history of tobacco use (Z87.891)
• hypertension (I10-I15)
• occupational exposure to environmental tobacco smoke (Z57.31)
• tobacco dependence (F17.-) = SMOKER
• tobacco use (Z72.0)
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Stroke Differentiation from TIA
Stroke Specificity in ICD-10
• Mechanism • Embolus • Thrombus
• Vessel involvement • Carotid – right or left • Cerebral – right of left
• Anterior • Middle • Posterior
• Vertebral – right of left • Basilar
• Consequences • Monoparesis or
hemiparesis • Right of left • Dominant or non-
dominant side • “Weakness” only codes
to these if documented as due to the stroke
• Aphasias • Dysarthrias • Dysphagias • Dementia
Acute Cerebral Infarctions
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ICD-10 Enhances Specificity Intracerebral Hemorrhage ICD-9-CM
• 431 Intracerebral hemorrhage
• Hemorrhage (of): • basilar • bulbar • cerebellar • cerebral • cerebromening
eal • cortical • internal
capsule • intrapontine • pontine • subcortical • ventricular
• Rupture of blood vessel in brain
ICD-10-CM
• I61 Nontraumatic intracerebral hemorrhage • I61.0 - Nontraumatic intracerebral hemorrhage in
hemisphere, subcortical • Deep intracerebral hemorrhage (nontraumatic)
• I61.1 Nontraumatic intracerebral hemorrhage in hemisphere, cortical • Cerebral lobe hemorrhage (nontraumatic) • Superficial intracerebral hemorrhage (nontraumatic)
• I61.2 Nontraumatic intracerebral hemorrhage in hemisphere, unspecified
• I61.3 Nontraumatic intracerebral hemorrhage in brain stem • I61.4 Nontraumatic intracerebral hemorrhage in cerebellum • I61.5 Nontraumatic intracerebral hemorrhage,
intraventricular • I61.6 Nontraumatic intracerebral hemorrhage, multiple
localized • I61.8 Other nontraumatic intracerebral hemorrhage • I61.9 Nontraumatic intracerebral hemorrhage, unspecified
Expansion from one code to 9 codes
Stroke in Meditech 5.67
Use of Imaging Reports Coding Clinic, 3rd Quarter, 2014, page 5
• Question: If a patient is diagnosed with a cerebral infarction or hemorrhagic stroke, can the imaging results be used to identify the specific vessel associated with these conditions?
• Answer: It is appropriate to utilize imaging reports to provide greater specificity of the anatomic site as documented by the physician. • Therefore, if a patient is diagnosed with a cerebral infarction
or hemorrhagic stroke, it would be appropriate to utilize the imaging report to determine the location of the stroke or infarction.
Comment: One cannot code a new diagnosis from the imaging study, just increased specificity of the anatomic location an already documented diagnosis
Intracranial Nontraumatic Hemorrhage of Newborns
APR SOI ROM
2 2
2 2
4 3
4 4
2 2
3 2
Admissions to Rehabilitation Late Effects of Stroke Sequelae of cerebrovascular disease
Category I69 is to be used to indicate conditions in I60-I67 as the cause of sequelae. The 'sequelae' include conditions specified as such or as residuals which may occur at any time after the onset of the causal condition
• Excludes1: • personal history of cerebral infarction without residual deficit
(Z86.73) • personal history of prolonged reversible ischemic neurologic deficit
(PRIND) (Z86.73) • personal history of reversible ischemic neurological deficit (RIND)
(Z86.73) • sequelae of traumatic intracranial injury (S06.-) • transient ischemic attack (TIA) (G45.9)
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While Hemiparesis = Hemiplegia, Monoparesis ≠ Monplegia
Monoparesis after a stroke = I69.x98 (depending on the underlying event) Plus M62.81 – Muscle weakness
Stroke Consequences “Sided” Weakness
43821
Late effects of cerebrovascular disease, hemiplegia affecting dominant side
Note: In ICD-9-CM and
ICD-10, hemiparesis
and hemiplegia share
the same code
Note: The right side is
presumed to be
dominant unless
documented otherwise
Note: Weakness of a
side can be interpreted
to be hemiparesis if
attributed to a stroke
I69051 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69052 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69151 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side
I69152 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side
I69251 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side
I69252 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side
I69351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
I69352 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side
I69851 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side
I69852 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side
I69951 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side
I69952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side
Stroke Consequences “Bilateral” “Sided” Weakness
• In ICD-10-CM, “quadriparesis” = “quadriplegia”
• Explicit documentation of neurologic quadriparesis due to (multiple) stroke(s) adds weight to hospital and physician risk adjustment
Other Neurological Muscle Weaknesses
If the coding system asks you to specify if a muscle weakness is due to
• A stroke or not
• Cerebral palsy
• Spinal cord injury
• Other specified neurological diseases
Pay attention!
Functional Quadriplegia (Quadraparesis) (versus Neurological Quadraplegia)
• The ICD-10-CM Official Guidelines is the only definition of this term on the planet - Not listed on PubMed.Gov
• Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. • It is not associated with neurologic deficit or injury, and
code R53.2 should not be used for cases of neurologic quadriplegia.
• It should only be assigned if functional quadriplegia is specifically documented in the medical record
Meditech 5.67
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Sequelae of Strokes
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ICD-10-CM Injury Codes Location Oriented
Episodes of Care Trauma and Complications Encounters
• Initial encounter: The first diagnosis of a condition or receiving active treatment for an injury or illness (even if in an established patient) • Fracture care: Initial care by ED physician, orthopaedist • Complications: Applies until all planned active treatment is completed
• Subsequent encounter: care during a period of healing or recovery (even if you’re the first MD to see the patient) • Fracture care: cast change, suture removal, etc. • Complications: Applies AFTER all planned active treatment is
completed
• Sequela: After the healing process is complete. • Permanent consequences to the fracture (e.g. malunions, nonunions)
Initial vs. Subsequent Rehabilitation Facilities • Question: The patient, who is status post treatment of multiple
fractures currently in the healing phase, is transferred to a rehabilitation facility. • At the rehab facility the patient is covered by a new physician that has
never seen the patient before. • Should the 7th character for the fractures be reported as “A” initial
encounter because it’s a new physician, even though the patient is considered to be in the healing phase?
• Answer: The key to selecting the 7th character for “initial encounter” is whether there is still active treatment (e.g., surgical treatment, emergency department encounter, or evaluation and continuing (ongoing) treatment). • The fact that the patient is new to the physician does not have any
relevance in determining the 7th character. • Rehabilitation services are not considered active treatment and the
encounter should be reported with the appropriate 7th character for “subsequent encounter.”
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Coding Clinic, First Quarter ICD-10 2015 Page: 21
Traumatic Fractures LEO C. FAR
• Location and Laterality • Proximal, mid, or distal shaft • Laterality (right vs. left)
• Episode of care (NEW) • “initial encounter” • “subsequent encounter” • “sequela”
• Open vs. closed
• Classifications • Salter classifications • Guistilo-Anderson
classification for open fractures (NEW)
• Others
• Fracture patterns, such as greenstick, oblique, spiral, comminuted
• Alignment • Displaced or nondisplaced • Angled, distracted, over-riding
• Results (NEW in ICD-10) • Routine or delayed healing • Union or nonunion
Multiple Trauma
CMG CMG Description (M=motor, C=cognitive, A=age) Relative Weight
Tier 1 Tier 2 Tier 3 None
201 Traumatic brain injury M>53.35 and C>23.5 0.8145 0.6636 0.5954 0.568
202 Traumatic brain injury M>44.25 and M<53.35 and C>23.5 1.0591 0.8629 0.7741 0.7385
203 Traumatic brain injury M>44.25 and C<23.5 1.2162 0.9909 0.889 0.8481
204 Traumatic brain injury M>40.65 and M<44.25 1.3397 1.0915 0.9793 0.9342
205 Traumatic brain injury M>28.75 and M<40.65 1.5924 1.2974 1.164 1.1104
206 Traumatic brain injury M>22.05 and M<28.75 1.9327 1.5747 1.4127 1.3477
207 Traumatic brain injury M<22.05 2.564 2.089 1.8741 1.788
401 Traumatic spinal cord injury M>48.45 1.0264 0.879 0.8131 0.7251
402 Traumatic spinal cord injury M>30.35 and M<48.45 1.4108 1.2081 1.1176 0.9966
403 Traumatic spinal cord injury M>16.05 and M<30.35 2.3059 1.9747 1.8268 1.6289
404 Traumatic spinal cord injury M<16.05 and A>63.5 4.0832 3.4967 3.2348 2.8845
405 Traumatic spinal cord injury M<16.05 and A<63.5 3.3355 2.8564 2.6425 2.3563
701 Fracture of lower extremity M>42.15 0.97 0.806 0.7727 0.7036
702 Fracture of lower extremity M>34.15 and M<42.15 1.2429 1.0327 0.9901 0.9016
703 Fracture of lower extremity M>28.15 and M<34.15 1.5056 1.2511 1.1994 1.0922
704 Fracture of lower extremity M<28.15 1.9359 1.6086 1.5421 1.4044
1701 Major multiple trauma without brain or spinal cord injury M>39.25 1.0432 0.929 0.8566 0.7881
1702 Major multiple trauma without brain or spinal cord injury M>31.05 and M<39.25 1.3109 1.1674 1.0764 0.9903
1703 Major multiple trauma without brain or spinal cord injury M>25.55 and M<31.05 1.5378 1.3694 1.2627 1.1617
1704 Major multiple trauma without brain or spinal cord injury M<25.55 1.9856 1.7682 1.6303 1.5
1801 Major multiple trauma with brain or spinal cord injury M>40.85 1.0662 0.9437 0.8082 0.7231
1802 Major multiple trauma with brain or spinal cord injury M>23.05 and M<40.85 1.6884 1.4945 1.2798 1.1451
1803 Major multiple trauma with brain or spinal cord injury M<23.05 2.8097 2.4869 2.1297 1.9055
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Multiple Significant Trauma With Craniotomy
Trauma diagnoses plus 2 organ system diagnoses
• Any closed or open fracture, dislocation, strain or sprain
• Concussion
• Nerve or blood vessel injuries
• Traumatic brain injury • Does not include “closed
head injury”
• Injury to any internal organs • Often omitted, such as
lung, cardiac, or renal contusions
• Subcutaneous emphysema
• Insect bites
3 organ system diagnoses
1. Head • Skull fracture; TBI; concussion
2. Chest • Fracture of 4 or more ribs or sternum; fx of larynx or trachea; injury to
heart, lung, or vessels (often not documented)
3. Abdomen • Injury to abdominal organs (often not documented), BV, or bowel;
compartment syndrome
4. Renal • Renal/adrenal Injury
5. Urinary • Injury to pelvic organs
6. Pelvis & spine • Fracture or crush injury; injury to nerve plexus
7. Upper limb • Fracture, dislocation, or nerve injury
8. Lower limb • Fracture, dislocation, or nerve injury
Potentially Missed Significant Traumas
• Nasal fractures
• Nerve injury
• Subcutaneous emphysema
• Puncture wounds
• Traumatic shock (elevated
lactate levels with evidence
of hypoperfusion)
• Traumatic anuria (not
oliguria)
• Traumatic muscle ischemia
• Most body contusions
• Blisters
• Insect bites
• In ICD-10 • Open fractures cannot be
coded without their Gustilo-
Anderson classification
• Concussions must have over 1
hour of unconsciousness
• Only Salter-Harris I–IV are
identified (not 5–9)
IRF Revenue Cycle
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Case Mix Groups (CMGs) drive IRF reimbursement
Rheumatoid Arthritis Without Organ Involvement
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Rheumatoid Arthritis Without Organ Involvement
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Rheumatoid Arthritis
35
To code rheumatoid arthritis correctly in ICD-10-CM, the physician must state if it is sero-positive (with rheumatoid factor) or sero-negative
Rheumatoid Arthritis Also not any organ dysfunction
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Meditech 5.67
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2015 Stroke CMGs
CMG CMG Description
(M=motor, C=cognitive, A=age) Relative Weight Average Length of Stay
Tier 1 Tier 2 Tier 3 None Tier 1 Tier 2 Tier 3 None
0101 Stroke M>51.05
0.7853 0.7150 0.6512 0.6248 9 10 8 8
0102 Stroke M>44.45 and M<51.05 and C>18.5
0.9836 0.8955 0.8155 0.7826 11 11 10 10
0103 Stroke M>44.45 and M<51.05 and C<18.5
1.1636 1.0594 0.9648 0.9258 12 14 12 12
0104 Stroke M>38.85 and M<44.45
1.2121 1.1036 1.0050 0.9644 13 13 12 12
0105 Stroke M>34.25 and M<38.85
1.4155 1.2888 1.1737 1.1262 14 14 14 14
0106 Stroke M>30.05 and M<34.25
1.6135 1.4691 1.3379 1.2838 16 16 15 15
0107 Stroke M>26.15 and M<30.05
1.8026 1.6412 1.4946 1.4342 17 19 17 17
0108 Stroke M<26.15 and A>84.5
2.2467 2.0456 1.8629 1.7876 22 24 21 21
0109 Stroke M>22.35 and M<26.15 and A<84.5
2.0570 1.8728 1.7055 1.6366 19 20 19 19
0110 Stroke M<22.35 and A<84.5
2.6928 2.4518 2.2328 2.1425 28 27 24 24
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2015 Brain Injury CMGs
CMG CMG Description
(M=motor, C=cognitive, A=age) Relative Weight Average Length of Stay
Tier 1 Tier 2 Tier 3 None Tier 1 Tier 2 Tier 3 None
0201 Traumatic brain injury
M>53.35 and C>23.5 0.8145 0.6636 0.5954 0.5680 10 9 8 8
0202
Traumatic brain injury
M>44.25 and M<53.35 and
C>23.5 1.0591 0.8629 0.7741 0.7385 12 10 9 10
0203 Traumatic brain injury
M>44.25 and C<23.5 1.2162 0.9909 0.8890 0.8481 13 12 12 11
0204 Traumatic brain injury
M>40.65 and M<44.25 1.3397 1.0915 0.9793 0.9342 12 13 12 12
0205 Traumatic brain injury
M>28.75 and M<40.65 1.5924 1.2974 1.1640 1.1104 14 15 14 14
0206 Traumatic brain injury
M>22.05 and M<28.75 1.9327 1.5747 1.4127 1.3477 19 18 16 16
0207 Traumatic brain injury
M<22.05 2.5640 2.0890 1.8741 1.7880 32 25 21 20
0301 Non-traumatic brain injury
M>41.05 1.1022 0.9324 0.8453 0.7798 10 11 10 10
0302 Non-traumatic brain injury
M>35.05 and M<41.05 1.3799 1.1673 1.0582 0.9762 13 13 12 12
0303 Non-traumatic brain injury
M>26.15 and M<35.05 1.6371 1.3849 1.2555 1.1583 16 15 14 14
0304 Non-traumatic brain injury
M<26.15 2.1541 1.8222 1.6520 1.5240 23 21 18 17
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2015 Spinal Cord Injury CMGs
CMG CMG Description
(M=motor, C=cognitive, A=age) Relative Weight Average Length of Stay
Tier 1 Tier 2 Tier 3 None Tier 1 Tier 2 Tier 3 None
0401 Traumatic spinal cord injury
M>48.45 1.0264 0.8790 0.8131 0.7251 12 12 10 9
0402 Traumatic spinal cord injury
M>30.35 and M<48.45 1.4108 1.2081 1.1176 0.9966 15 14 14 13
0403 Traumatic spinal cord injury
M>16.05 and M<30.35 2.3059 1.9747 1.8268 1.6289 26 21 20 20
0404 Traumatic spinal cord injury
M<16.05 and A>63.5 4.0832 3.4967 3.2348 2.8845 54 40 33 33
0405 Traumatic spinal cord injury
M<16.05 and A<63.5 3.3355 2.8564 2.6425 2.3563 26 34 29 27
0501 Non-traumatic spinal cord injury
M>51.35 0.8418 0.6804 0.6237 0.5643 9 10 9 8
0502 Non-traumatic spinal cord injury
M>40.15 and M<51.35 1.1580 0.9359 0.8579 0.7763 11 12 10 10
0503 Non-traumatic spinal cord injury
M>31.25 and M<40.15 1.4373 1.1616 1.0648 0.9635 15 13 13 12
0504 Non-traumatic spinal cord injury
M>29.25 and M<31.25 1.6935 1.3687 1.2546 1.1352 17 15 15 14
0505 Non-traumatic spinal cord injury
M>23.75 and M<29.25 1.9365 1.5651 1.4346 1.2981 20 17 17 16
0506 Non-traumatic spinal cord injury
M<23.75 2.7066 2.1875 2.0052 1.8144 26 25 23 21
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Tier 1 Diagnoses
Code Choice Code Title Tier J38.01 Paralysis of vocal cords and larynx, unilateral 1 J38.02 Paralysis of vocal cords and larynx, bilateral 1 J38.4 Edema of larynx 1 Z43.0 Encounter for attention to tracheostomy 1 Z93.0 Tracheostomy status 1 Z99.2 Dependence on renal dialysis 1
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Tier 2 Diagnoses Code Choice Code Title Tier A04.7 Enterocolitis due to Clostridium difficile 2 A04.8 Other specified bacterial intestinal infections 2
B96.5 Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere 2
I69.091 Dysphagia following nontraumatic subarachnoid hemorrhage 2 I69.191 Dysphagia following nontraumatic intracerebral hemorrhage 2 I69.291 Dysphagia following other nontraumatic intracranial hemorrhage 2 I69.391 Dysphagia following cerebral infarction 2 I69.891 Dysphagia following other cerebrovascular disease 2 I69.991 Dysphagia following unspecified cerebrovascular disease 2 K91.2 Postsurgical malabsorption, not elsewhere classified 2 R13.0 Aphagia 2 R13.10 Dysphagia, unspecified 2 R13.11 Dysphagia, oral phase 2 R13.12 Dysphagia, oropharyngeal phase 2 R13.13 Dysphagia, pharyngeal phase 2 R13.14 Dysphagia, pharyngoesophageal phase 2 R13.19 Other dysphagia 2
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Tier 3 Diagnoses
• Asymptomatic Hepatitis C
• B20 HIV-Disease • Code for asymptomatic HIV doesn’t add weight
• Diabetes with complications • Includes hyperglycemia (Hgb A1C > 7 or multiple BS over
250) • Includes all other specified complications
• Document all consequences of old and current strokes • Vocal cord paralysis • Hemiparesis
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Tier 3 Diagnoses
• Heart failure if documented as systolic or diastolic • Heart failure NOS does not qualify
• Pneumonia if still treated
• Acute and chronic pulmonary insufficiency following surgery
• Cellulitis
• Peripheral Atherosclerosis • With ulcer
• With gangrene
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