hello and welcome to the CPC certification review training with Legacy this training is designed to assist you in passing the CPC certification exam this course is not designed for beginners you should understand the coding process prior to taking this review there are six questions from the 30 000 series of codes focusing on surgical procedures performed on the respiratory system cardiovascular system hemic and lymphatic systems and on the mediastinum and diaphragm understanding the anatomy of the respiratory system is critical to proper code selection the respiratory system is made up of several structures that work together to facilitate breathing and gas exchange please take a moment to review the anatomy of the respiratory system the mediastinum and diaphragm are both structures that are important for the functioning of the respiratory system the mediastinum is an area in the middle of the chest that separates the two lungs it contains several important structures including the heart grape vessels such as the aorta trachea esophagus thymus gland lymph nodes and nerves the mediastinum plays an important role in protecting and supporting these structures as well as facilitating communication and transport between them the diaphragm is a large dome-shaped muscle that separates the chest cavity from the abdominal cavity it is the primary muscle responsible for breathing as it contracts and flattens downward during inhalation increasing the volume of the chest cavity and drawing air into the lungs during exhalation the diaphragm relaxes and moves upwards decreasing the volume of chest cavity and forcing air out of the lungs the diaphragm also plays an important role in protecting the organs in the abdominal cavity such as the liver and spleen by providing a barrier between them and the chest cavity the lymphatic system is part of the immune system it runs through the body similar to the way the cardiovascular system does the primary function of the lymphatic system is to transport lymph a fluid containing infection fighting white blood cells or lymphocytes throughout the body in addition to the immune functions the lymphatic system is a network of tissues and organs that helps rid the body of toxins waste and other unwanted materials by removing additional fluid from tissues throughout the body and absorbing or moving fatty acids the spleen is an organ in the upper portion of the abdomen located to the left of the stomach the spleen is a blood filtering organ as well as a receptacle for red blood cells it also plays a role in the immune system by producing lymphocytes that are involved in the infection fighting process common diagnosis codes for the respiratory system are listed here please take a moment to review these diagnoses vaping or the use of e-cigarettes has been associated with a number of health problems those are located in chapter 22. this is the only section of codes in the ICD-10 that is out of numeric sequence here's a tip at the end of chapter 19 which are the s and t codes make a note for the page number where the u-codes are found listed are several diagnosis associated with the mediastinum and diaphragm and hemic and lymphatic system please familiarize yourself with those listed on the screen let's take a moment to discuss one listed diaphragmic herniation also known as diaphragmic rupture is a condition where an opening or weakness in the diaphragm allows organs or tissues from the abdomen to protrude into the chest cavity this can lead to various symptoms depending on the size and location of the hernia there are two types of diaphragmic hernias congenital and acquired congenital diaphragmic hernias are present at birth and caused by a defect in the development of the diaphragm during fetal growth acquired diaphragmic hernias can occur later in life due to trauma surgery or other medical conditions the symptoms of a diaphragmic herniation can vary depending on the size and location of the hernia small hernias may not cause any symptoms while larger hernias can cause symptoms such as a shortness of breath chest pain abdominal pain nausea and vomiting bowel obstruction acid reflux and a rapid heart rate diaphragmic herniation is typically diagnosed using imaging test such as x-rays CT scans or MRI treatment of this type of hernia depends on the size and location of the hernia as well as the severity of the symptoms surgery is often required to repair the hernia and return the organs to their proper position if left untreated a diaphragmic hernia can lead to serious complications such as respiratory failure shock and organ damage there are some overarching guidelines for the respiratory system as with all CPT codes be careful to review all parenthetical statements Throughout the chapter there is specific guidance regarding specific use of codes found in the parenthetical statements most of the codes in the respiratory section are considered unilateral unless specifically noted as unilateral or bilateral make note of those specific codes throughout the book If the code is not specified as unilateral or bilateral it is assumed to be unilateral to report it as bilateral append modifier 50 to the code Rhino is the root word for nose renotomy is the cutting into the nose under the excision section we have codes for biopsies removal of lesions cysts polyps and turbinates note the approach for these excisions intranasal versus extra nasal turbinates are small soft bones found in the nose three on either side which are the inferior metal and Superior turbinates turbinates control and maintain airflow these bones can get in the way of breathing due to swelling enlargement or congenital problems when they become diseased they may have to be removed when coating removal or excision of the turbinate the coats are reported per turbinate not per side of the nose a rhinectomy is the removal of the nose this can be partial or total and is usually reported with closure reconstruction codes as noted in the parenthetical statement below the codes under the introduction section we see codes for therapeutic injections into the turbinates as well as placement of a prosthesis also known as a button into the nasal septum to close a hole in the nasal septum there are several codes to describe removal of a nasal foreign body removal can be done easily via intranasal removal in the office when anesthesia is required this is done in the hospital there is an additional code for removal of a foreign body by lateral rhinotomy or cutting into the side of the nose to remove the foreign material rhinoplasty is the repair of the nose it is usually considered to be cosmetic it can either be primary or secondary it can also be done as a result of A congenital cleft lip or palate septoplasty is surgery to correct deficits or deformities of the nasal septum it is performed for a deviated septum a fistula is an abnormal passageway between two organs or body systems another birth defect is oral mascular fistula which is an abnormal passageway between the sinuses and the roof of the mouth in oral maxillary fistula can also be caused by trauma or as a complication from removing a tooth the destruction category contains codes for ablation of turbinite mucosa the turbinate mucosa is a soft tissue covering the bones of the turbinates pay attention to the parenthetical instructions note these codes are used whether the procedure is done unilaterally or bilaterally and modifier 50 would not be applicable these codes only pertain to the inferior turbinates according to the parenthetical refer to the unlisted codes for ablation of the Superior or middle turbinates the coding concepts for control of nosebleeds includes anatomical site and complexity here's a tip coats for nosebleeds typically are unilateral and the use of the RT or LT modifier would be appropriate a bilateral nosebleed will require the addition of modifier 50 as indicated in the parenthetical instructions found in your CPT manual there are four pairs of sinuses starting superiorly frontal ethmoid sphenoid and maxillary take care when assigning codes in this section to note the correct sinus is being reported in the code underline or highlight the sinus identified in each code for correct code selection be careful to identify the approach by highlighting underlining or circling the difference as the codes are similar between endoscopic and open under the open codes there are codes for obliterative or non-obliterative procedures obliterative procedures include the complete removal of a disease or structure which in this case means complete removal of the sinus tissue the endoscopy coats are next as with all endoscopy codes surgical or therapeutic services always include diagnostic services the guidelines list the specific Anatomy that would be expected to be reviewed and documented note if all elements are not fully examined append modifier 52 if a repeat exam is not planned and modifier 53 if a repeat exam is planned larynotomy is an incision in the voice box to remove a tumor or an abnormal air sac requiring removal of all or part of the vocal cord also called a chordectomy a larynectomy is the partial or total removal of the voice box the approach determines the code assignment a fair and larynectomy involves removal of the pharynx and the larynx the pharynx is a passageway connecting the nose and the mouth to the esophagus whether reconstruction is done determines the correct code selection under the endoscopy guidelines there are specific anatomical sites that must be reviewed and documented codes include with or without the use of operative microscope since there are codes that include the use of operative microscope we do not code separately for the operative microscope endoscopy can be performed either direct or indirect there are numerous codes for endoscopic exam of the trachea and bronchi take care to review all the various bronchoscopy codes and the services that can be performed such as lung biopsies brushings removal of foreign bodies Etc there are many parenthetical statement instructions regarding the number of times specific codes can be billed there are a small section of codes Under excision and repair the Carina is the last string of cartilage at the bottom of the trachea it bifurcates into the right and left bronchi it may be removed due to cancer at which point it will be reconstructed the remaining excisional codes are reported based on what is being excised such as a stenosis a tumor or a traumatized section of the trachea with stenosis a section of the trachea may be resected in the case of anastomosis the proximal portion and the distal portion of the trachea are sutured back together the last couple of codes in excision and repair were Port closing as a tracheostomy or for the tracheostomy scar revision which can be performed after the removal of a tracheostomy incisional codes for the lungs and pleura contain codes for thoracostomy thoracotomy and pneumonia ostomy a thoracostomy is an opening made into the thoracic cavity a thoracotomy is an incision between two ribs to access the lungs once the lung is accessed a biopsy can be taken also it is possible to explore the lung implora procedure codes for thoracostomies are selected based on the procedure performed once the chest wall has been opened and accessed to the lung has been gained thoracostomies are typically performed to treat a lung abscess lung cancer or blebs which are balloon-like sacs pressing on the lung and are also called lung cyst a pneumonia ostomy code report incising into the lung to drain an abscess or cyst decorticization is the removal of a constricting layer of tissue like scar tissue from the surface of the lungs to allow for full lung expansion under the biopsy codes there are directions regarding Imaging guidance or fine needle aspirations there are reminders about different approaches for biopsies like open versus percutaneous needle plurectomy codes describe removing parietal pleura or the lining of the chest wall note this is listed as a separate procedure which means that it is typically included as part of a larger procedure and should only be reported if it is the only service performed the removal codes address a thoracentesis or placement of a needle into the pleural space between the lungs and the chest wall to remove excess fluids from the pleural space to help you breathe easier it also contains codes that describe whether an entire lung or a single lobe or segment is removed as well as if different resections are performed the major types of lung surgery include wedge resection which is the removal of a small wedge-shaped piece of lung a lobectomy which is the removal of an entire lobe of a lung or a pneumonectomy which is the removal of an entire lung placement of a chest tube is useful in draining fluids from the chest or to allow air to be released from the chest cavity to heal a pneumonothorax or a collapsed lung surgical thoroscopy is an endoscopic exam of the thoracic cavity it is known here as a video assisted thoracic surgery that's services are diagnostic or surgical in nature recall that surgical or therapeutic services always include diagnostic services there are multiple Services included in this category note that many of these Services have similar codes that are open in nature rather than endoscopic all transplants have three parts to them Harvest back bench and insertion harvesting includes removal of the lung from a donor and cold preservation of the organ prior to transplant most lungs come from a cadaver donor but rarely a lung can be taken from a human donor instead back bench work is done by a different provider who prepares the organ for transplantation including examining it for abnormalities or injuries residual tissue from the donor is removed from the organ with particular attention paid to the vessels that will be attached to the transplant recipient finally the new organ is placed in the recipient the final section of codes relate to surgical collapse therapy and thoracoplasty in some cases pneumonothorax is therapeutically initiated for certain conditions such as tuberculosis thoracoplasty is a treatment for chronic empaia or collection of Plus in the pleural cavity an extensive unroofing of the Empire Space by resecting overlying ribs and partial removal of the lining of the chest cavity the area is packed with gauze this takes place over several days and all services are included in the single procedure in other cases section of the rib or entire ribs are removed for a therapeutic treatment purposes lung lavage is used to wash out the lungs with the aid of a bronchoscopy additional codes in this section are for tumor ablation either by radio frequency or cryoablation in the medicine section of CPT there are specific codes related to the pulmonary section ventilators are machines used to assist with breathing usually in a patient that cannot breathe for themselves this can be due to trauma or following surgery a specialist called a pulmonologist or an intensivist generally manages ventilator settings spirometry measures inhalation and exhalation and is very helpful in managing asthma other pulmonary testing is used to evaluate specific aspects of breathing in most instances these tests are administered by a pulmonary technician and interpreted by a physician a physician specializing in Respiratory Care is called a pulmonologist when based in a hospital or intensive care unit this specialist may be an intensivist these coats are found at the very end of the cardiovascular section of CPT the mediastinum is the central compartment of the thoracic or chest cavity mediastinotomy codes are differentiated by approach cervical versus transthoracic there are additional codes for excision or resection of medial spinal cysts or tumor the diaphragm is a dome-shaped muscular partition between the thoracic and the abdominal cavities it is the chief muscle of inspiration and forms the floor of the thoracic cavity with inspiration the diaphragm descends during expiration it moves superiorly the hemic and lymphatic system codes are found just before the mediastinum and diaphragm codes at the end of the cardiovascular section of CPT the lymphatic system is an important part of the immune system that helps to fight off infections and diseases it consists of the lymphatic vessels lymph nodes and lymph node organs such as the spleen thymus and tonsils lymph nodes are small Bean shape structures that are found throughout the body they are an important part of the lymphatic system because they act as filters that trap and remove harmful substances such as bacteria viruses and cancer cells from the lymphatic fluid lymph nodes contain immune cells such as lymphocytes and macrophage which help to identify and attack these harmful substances lymphatic channels are networks of thin branching vessels that are similar in structure to blood vessels they transport lymphatic fluid a clear fluid that contains white blood cells throughout the body lymphatic channels are located in many different tissues and organs including the skin lungs digestive system and lymph node organs the lymphatic system works by collecting lymphatic fluid from tissues and organs and transporting it to the lymph nodes the lymph nodes filter the lymphatic fluid and remove any harmful substances that may be present the purified lymphatic fluid is then transported back into the bloodstream when the body is fighting an infection the lymph nodes can become enlarged and tender as they work to remove harmful substances from the lymphatic fluid this is why doctors often check for swollen lymph nodes during a physical exam in addition to filtering lymphatic fluid the lymphatic system plays an important role in maintaining fluid balance in the body by returning excess fluid from the tissue back to the bloodstream this helps to prevent swelling and edema in the body there are some of the procedures associated with this system please familiarize yourself with them the four chambers of the heart serve as a brief storage Depot for blood the internal layer of the heart is a smooth lining of endocardium this thin layer is very slippery and smooth it allows blood to flow through the heart without sticking or stopping blood that sits tends to clot the working muscle of the heart is The myocardium when you look at a cross-section of the heart it is obvious that the left side is thicker and more muscular than the right the left ventricle must push blood from the heart to the top of our heads our fingertips and the end of our toes cardiac muscle is not under voluntary control the heart rate is controlled electronically by special cardiac muscle fibers in the pacemaker portion of the heart which is controlled by anatomic or involuntary nervous system the external layer of the heart is the epicardium it is also smooth the exterior surface of the heart contains the coronary arteries critically important these arteries feed and nourish heart muscle coronary or cardiac arteries provide the heart muscle with necessary nutrients and oxygen the next layer is the pericardium a double walled membrane enclosing the heart and the roots of the great vessels the visceral pericardium adheres to the surface of the heart the parietal epicardium is a tough membrane which covers the heart the space between the layers contains a small amount of fluid serving primarily as a lubricant between these layers we will discuss the cardiac valves on the next slide we are going to follow the blood as it moves through the heart and body next keep in mind that these processes are happening at the same time through the body but for sake of discussion we are going to walk through it one step at a time deoxygenated blood enters the right atrium from the body via large vessels the superior and inferior vena cava during diastole blood flows down from the right atrium through the tricuspid valve into the right ventricle during systole the heart contracts and blood is pushed from the right ventricle through the pulmonary valve into the pulmonary artery deoxygenated blood flows through the pulmonary artery away from the heart and to the lungs where gas exchange occurs oxygenated blood is picked up and returned to the heart through the pulmonary vein oxygenated blood enters into the left atrium from the pulmonary vein during diastole blood flows down from the left atrium through the mitral valve into the left ventricle during systole the heart contracts and blood is forced from the left ventricle through the aortic valve into the aorta from the aorta blood is pushed into the arteries to carry oxygenated blood through the body it drops off the oxygenated blood and picks up the deoxygenated blood which is returned to the Heart by the veins simultaneously oxygenated blood from the lungs enters the left atrium via the pulmonary veins during diastole blood flows from the Atria to the ventricles through the right and left atrioventricle valves openings from the right atrium to the right ventricle and from the left atrium to the left ventricle even though both Atria do not contract blood will flow from the Atria into the ventricles without contraction because the ventricles are both empty after the ventricles are filled with blood they contract which is systole blood is forced into the pulmonary artery from the right ventricle and into the aorta from the left ventricle because the tricuspid and bicuspid valves close off the artery arterial ventricle openings this prevents a backflow of blood from the ventricles to the Atria the coordinate tendonae also known as the heartstrings which connect the valves Leaf leaflets to the papillary muscles prevent aversion of the leaflets during systole the contraction of The ventricle musculature empties the ventricles opening the semilunar valves of the aorta and the pulmonary artery allowing blood to flow deoxygenated blood flows through the pulmonary arteries to the lungs to be oxygenated oxygenated blood in the aorta is delivered to the body the cycle is repeated as deoxygenated blood from the body again fills the right atrium and oxygenated blood from the lungs fills the left atrium there is an electrical conduction system in the heart the conduction begins in the sinoatrial node of the right atrium the SA node is also known as Nature's pacemaker as it sets the pace for the heart electrical impulses go from the SA node to the AV node and then down along the septum via the bundle of His from the bundle of His the electrical impulses move across the bottom of the heart via the purkinje fibers the purkinje fibers are tiny signaling devices within the electrical system Along The ventricle at the Apex electrical signals cause the right and left Atria to contract at the same time this is followed by contraction of the ventricles systole arteries carry oxygenated blood away from the heart and out to the rest of the body veins carry deoxygenated blood back to the heart from the capillary beds there is one set of exceptions in the body pulmonary artery carries deoxygenated blood away from the heart and out to the lungs pulmonary vein carries oxygenated blood back to the heart from the lungs to be pumped out to the rest of the body there are five circulation systems in the body two of them are discussed here one is the pulmonary circulation system which pushes blood from the right ventricle through the pulmonary valve out the pulmonary artery to take deoxygenated blood to the lungs to drop off carbon dioxide and pick up oxygen blood is returned to the heart through the pulmonary vein and returns oxygenated blood to the left atrium the systemic circulation is the next phase of blood circulation when the oxygenated blood flows from the left atrium to the left ventricle it moves from the left ventricle out through the aorta to the rest of the body pertinent diagnosis codes for Cardiology are found throughout the icd-10-cm book there are many diagnosis codes related to hypertension and the comorbid conditions associated with hypertension found in icd-10-cm the guidelines associated with these diagnosis are important to review as are the code also notes it is important to note that per the icd-10-cm guidelines there is a presumed causal relationship that exists between hypertension and heart disease and hypertension and kidney disease as a result of the presumed causal relationship if the patient has both conditions present coders should assign the combination code that exists only if the physician specifically states that the two conditions are not related should the two conditions be reported separately many ICD-10 codes differentiate between native coronary arteries and bypassed coronary arteries the term native coronary arteries means that the patient has not had a heart transplant who has never had a coronary artery bypass procedure or a patient who has had percutaneous transluminary coronary angioplasty who has been readmitted for another occlusion or blockage the patient still has the same coronary arteries they were born with endocarditis is an inflammation or infection of the inner lining the endocardium of the heart which if left untreated can damage or destroy the heart valves heart failure occurs when the heart is unable to pump enough blood to supply the rest of the organs in the body heart failure is also known as congestive heart failure or CHF pericarditis is an inflammation or infection of the sac that surrounds the heart also known as the pericardium valve disorders impact the valves of the heart the tricuspus bicuspus which we also known as the mitral valve and the pulmonary and aortic valves there are different types of valve disorders such as stenosis regurgitation and prolapse myocardial infarction is also known as a heart attack there is a decrease in blood flow in the coronary arteries to the heart muscle causing the heart muscle to die acute myocardial infarction is classified based on the affected heart tissue and the time frame in which it occurs it also is based on whether the artery was completely blocked acute MI is considered acute for four weeks or 28 days there is only one code for an old Mi which is I 25.2 with an old Mi the patient is asymptomatic and does not require any further treatment if the patient requires Continued Care or is symptomatic after four weeks the appropriate Aftercare code is used and not a code from category i21 Cardiology coding uses codes from three different sections of CPT surgical coding Radiology coding and the medicine section cardiac muscle contractions are not under voluntary control heart rate is regulated by a natural pacemaker comprised of special cardiac muscle fibers under control of the autonomic nervous system as described earlier 7 artificial pacemaker it refers to an artificial or man-made system to regulate the rate of activity a pacing cardioverter defibrillator system is a man-made device placed in the chest to monitor heart rhythm and detect irregular heartbeats in the case of irregular heartbeats the ICD will deliver electrical shocks to the heart to fix an abnormal heart rhythm to code either a pacemaker system or an ICD system coders must know the information presented on the slide there are many aspects to Pacemaker defibrillator insertion please take a moment to review the information on this slide as it is vital for coders to find the proper code an implantable loop recorder is a device that records your heart rhythm continuously for up to three years it records the electrical signals of your heart and allows remote monitoring of heart function implantable hemodynamic monitors are used for long-term monitoring of pulmonary artery pressures devices are placed via right heart catheterization in the pulmonary artery for purposes of monitoring patients with heart failure cardiac valve procedures may be done via open or percutaneous approach Services include plasti which is the surgical repair and automate which is a cutting into the chest and or valve for repair and or replacement there are numerous guidelines associated with valve surgeries to be repaired coronary arteries are critical to the function of the heart coronary arteries arise from the aorta and are small vessels feeding oxygen and nutrients to The myocardium each coronary artery has a specific name the three most common are the left anterior descending right coronary and left circumflex one of the treatments for a blocked coronary artery is bypassing the blockages in the vessels with grafted vessels known as a cabbage or coronary artery bypass graph to restore blood flow there are three sets of codes used to report cabbage which report the type of material used and the number of biopsies done with the material there are numerous add-on codes that may be built with cabbage Services most of the add-on codes relate to the harvesting of vessels from other parts of the body to be used as graft materials if cabbage is performed more than one month after a previous cabbage or valve procedure a re-operation code should be appended to the Cabbage service there are other bypass graft codes in CPT these procedures restore blood flow to several body areas other than the coronary vessels code selection is made by type of graft and the location type includes an autographed which is tissue or organ transferred by grafting into a new position in the body of the same individual using a vein or artery synonyms include Auto genius and autologous synthetic graphs may also be used central venous access devices are placed for obtaining quick frequent access to the bloodstream per the guidelines to be a central venous access device the tip of the catheter must terminate in the subclavian artery brachiocephalic artery the iliac artery or either the Superior or inferior vena cava there are codes for the type of procedure whether the catheter was tunneled or not whether there was a port or a pump used and the age of the patient a tunnel catheter is inserted and advanced to its final point non-tunneled is through a short track which is from the skin entry site directly into the point of cannulation Interventional Cardiology Radiology is a branch of medicine which uses minimally invasive techniques to diagnose and treat diseases using fluoroscopic ultrasound or other guidance a catheter is threaded into vessels to perform procedures Services reported should be coded to the highest or deepest level accessed within a vascular family any branches that the physician must pass through to get to his final destination are not coded any additional branches that are investigated are separately reportable there are numerous rules for vascular injections and appendix L additionally is used extensively in this section hemodialysis is filtration of the blood to replace the vital function of the kidneys when the patient's kidneys are no longer fully functioning it requires access to the circulation which can involve a cannula arterial venous anastomosis or fistula or shunt portal decompression is performed to treat portal hypertension due to hepatic venous outflow obstruction a transjugular intrahepatic porto-systemic shunt also known as tips is a percutaneously created connection within the liver between the portal and systemic circulations transcatheter procedures for arterial and venous thrombectomy and other catheter procedures that are very specific such as insertion and removal of vena cava filters embolization of tumors or fibroids and stent placement endovascular revascularization can be performed open or percutaneously to treat occlusive diseases in the lower extremities there are four treatments that can be performed as indicated on the slide treatments may be done in three different vascular territories listed below guidelines are extensive regarding the different territories and how to apply the cpts and the associated add-on codes according to the guidelines for endovascular revascularization there are many services bundled into the service performance please see those listed on this slide throughout CPT there are instructions for the use of diagnostic angiography angiography may be separately reportable if performed at a time other than during an intervention or surgical service if it is defined as part of the intervention description it is not separately reportable there are numerous listings in the medicine section related to Cardiology among Services found here include cardiopulmonary resuscitation or CPR and cardioversion during which a shock is administered to the heart to convert an abnormal heart rhythm into a normal one please note that during percutaneous coronary interventions modifier 59 is not used to identify separate sites here separate sites are identified by the use of the site-specific modifiers such as LD LC and RC during PCI each branch is reported on its own please see the examples listed for ECG and stress testing the key concepts for code selection include the type of procedure such as with interpretation and Report tracing only interpretation and Report only please take a moment to review the table on this slide cardiac catheterization also known as cardiac cath is a medical procedure that involves inserting a thin flexible tube called a catheter into a blood vessel in the arm or leg and threading it up to the heart the procedure is used to diagnose and treat a variety of heart conditions including coronary artery disease heart valve problems and heart defects during cardiac catheterization the patient is given a local anesthetic to numb the area or the catheter will be inserted the doctor then makes a small incision and inserts the catheter into a blood vessel the catheter is then guided through the blood vessel and up to the heart using Imaging techniques such as x-rays or ultrasound once the catheter is in place the doctor can perform a number of different procedures depending on the reason for the catheterization examples of the codes can be found on this slide please take a moment to review thank you for joining us for this review if you would like more details about our intensive CPC training or any of our other training programs please visit our website at medicalbilco.com