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Sound

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- 08.10.17 Adv Comm Meeting reccs:
- Focus of the meeting is charting 
- PE - be sure the PE and the plan mirror each other
- April 2017 - 85% of my PEs were copied forward
- add subjective comments to PE, like "less anxious"
- list of subjective comments:
- less anxious
- fewer pain complaints
- no abdominal pain with PO now, etc

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Good Coding Examples:
- Underweight w/ BMI 17.3 2/2 age related debility, decreased PO intake tx: IVF, labs, albumin, encourage PO.
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Can one stay on the partner / onboard path part time ?
- ask Robin Higgens HR - SoundPhysicians 253-682-6030
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-- Dr. K's Smart Phrases
.wetread - display all radiological images
.mscvitals - import vitals for past 24 hours
.aaltx20 - alt for 20 days
.msccr - creatinine x 2
.street
.allproviders

Numbers:
- CMU - 82852
- Radiology - 57231
- Cardiology - 84604

Case Management
- Racheal - 89771 - C4
- Kim - 89773 - A1
- Ashley - 89773 - A1
- Weekend Case Mgt Number: 632-9773
Courier: Tom - United Courier 200-2212
- Melissa 84903
- Kelly clinical 86561
- Angie McCloud, IT Site Specialist: - 513-504-8878
James Eppley 859-653-4558 Psychiatry Covering M.D.

Pam Tritch, RN |Regional Nurse Manager |Sound Physicians | 8041 Hosbrook Rd., Suite 410, Cincinnati, OH 45236 | T: 513-265-5643 | ptritch@soundphysicians.com

Amanda Johnson, Manager, Immigration and Travel Services, will be the point of contact to coordinate support of our immigration attorney. Amanda may be reached on phone or by email: 253-275-7094 (mobile) or ajohnson@soundphysicians.com. 

--- Transitional Care Compensation Plan
Advanced Care Planning
- ACP1 (99497) - first 30 minutes
- ACP2 (99498) - each additional 30 minutes
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- turn this into a dot phrase (BTW, this is CHF-X.com)
- CHF patient admission
- Use the CHF order set
- Consult CHF nurse
- Update Problem list to reflect HF diagnosis
- Document NYHA Class
- Be sure LV function measured - prior to admission, during, or after D/C - document this
- Discharging a CHF patient
- Order HF F/U appointment within 7 days
- Order measure of LV function if not done as above
- Document NYHA class
- IF <40% - order these medications:
- ACEI / ARB / ARNI - document contraindications if not prescribed (allergy, mod-severe AS, 
-- angioedema, hyperkalemia, hypotension, renal artery stenosis, worsening renal function or,
-- renal disease or dysfunction.
- Evidence based BB - carvedilol, metoprolol CR/XL, bisoprolol - document contraindications if not
-- prescribed (allergy, 2nd or 3rd degree heart block without PM, COPD, severe hypotension, etc.)

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- Topics within this bracket are relative to billing optimization.
- HCC - Hierarchial Decision Category - denotes to CMC pt is more sick, get higher reimbursement REF
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AIDET 
Acknowledge
Show a positive attitude.
Make your customers feel like you know them.
Put patients and families at ease and make them feel comfortable.
Ask permission to enter a room.
Introduce
Manage up yourself, your coworkers, other departments, and other physicians/nurses
Duration
Communicate how long discussion, paperwork, preparation, tests/results, and waiting times will be.
Explanation
Help patients and family members understand what you will be doing and why.
Clarify expectations and future plans.
Thank You
Let patients and referral sources know that you enjoy working with them.
Thank the family for using us and entrusting us with the care of their loved one.

For the Nocturnist
Noelle Stoner, Clinical Supervisor, has offered to support Dr. Childers and complete the observations on the Nocturnist.  I will let you know the date and time. 

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- CM numbers at MHA

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ARU
Acute  Rehab Referral Line: 513-498-8449
- Angela Caliguri RN Clinical Liaison
- Anna Maxey MD 513-673-6195
- Janet Simmer RN Program Director: 513-781-8182
Admission Requirement: Need for intensive therapy program consisting of:
- at least 2 disciplines (PT, OT, SLP) at least 3 hrs, 5 days a week, or at least 15 hrs in 7 days consecutive.
- medically stable, demonstrate sufficient endurance and potential to participate in a rehab program.
- demonstrate potential for making significant improvement in functional capabilities
- demonstrate willingness, along with family, to be involved in a rehabilitation program
require a coordinated interdisciplinary approach to providing rehabilitation
Betty Joe - Kindred Rehabilitation Care
Jane Duffy, M.D. - Anesthesia
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Zosyvn renal toxicity as noted per ID
- "I would favor giving Cefepime over Zosyn given the increased nephrotoxicity
associated with the latter". 
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Clinical Documentation Pearl – Age Related Debility
When a patient is admitted for symptoms that include falls, generalized weakness, fatigue, or deconditioning (not the doc, the patient) – consider using the diagnosis “age related debility” if applicable.  Relate the symptom to the diagnosis … “Fall due to age related debility.”
age related debility, documentation: "Fall due to age-related debility" 
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Beta-Hydroxybutyrate Better Monitor of Ketosis and Acetone
The chemistry lab now has in house beta-hydroxybutyrate, a quantitative test for the detection of clinically significant ketosis.  This replaces the semi-quantitative acetone test, which is no longer available.  Beta-hydroxybutyrate is the ketoacid present in the greatest amount in serum, accounting for 75% of the ketone bodies which also contain acetoacetate and acetone.  During ketosis, beta-hydroxybutyrate has been shown to be a better index of ketoacidosis.  Test is available 7 days per week, 24 hours per day with a turnaround time of 20 minutes.  Epic order [LAB6382], reference value < 0.27 mmol/L. 
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Condition on discharge would include the patients discharge condition such as:
Stable
Fair
Poor
Expired
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Electronic COC, Home Care and DME 
(Tips for Hospitalists)
Electronic COC:
Placed in the "Discharge Instructions" section, and may be edited by the entire multi-disciplinary team (nursing, case management, physicians and other providers).
Should typically be entered by Case Management.  Other providers may also initiate or enter the eCOC template. (Smartphrase .MHACOC)
Used for all discharges to facilities (SNF, ECF, LTAC, IP Rehab, etc), and Home Health Care.
Physician responsibilities
Responsible for completing “Physician Section”
Verify accuracy of discharge diagnoses (default will pull in Active Problem List)
Comment on Prognosis and Condition at Discharge
Answer if any changes to H&P (just say no)
Similar to paper COC, fill out the “box” with any recommended follow-up, labs or other treatments. (IV antibiotics, fluids, etc).  Wound Care, ID and other specialists have been asked to use the “box” when applicable.
Electronic signature (left to click, right to stick)
As the COC and the “box” are intended for the receiving facility/providers, any Discharge Instructions directed at the patient/family should be entered into the "Patient Discharge Instructions" section AFTER the eCOC.  

Home Care:
An order must be placed in EPIC (active orders not discharge orders) for Home Health care 
Search “home care” to find the order - Inpatient consult to Home Care needs 
Complete all pertinent fields and sign. Hit F3 to enlarge the comment section.
Tip - As the home care order fields are cumbersome, consider filling out the order with as much generic information as possible then save to your preference list. We created a smartphrase .SOUNDHHCORDER for this purpose, just enter it into the comment section of the order when creating your preference list entry. 
Complete an Electronic COC
Document medical necessity for Home Care in either a progress note or discharge summary.
Enter .HOMECAREMEDNEC in a note and complete the required fields

DME:
An order must be placed in EPIC (active orders not discharge orders) for certain DME items (Oxygen, Nebulizer, Hospital Bed, etc). Example, search for DME Oxygen for the order. 
Case Management can provide guidance if other DME requires an order or not. 
Complete pertinent fields and sign. Hit F3 to enlarge the comment section.
Document medical necessity for each DME item in either a progress note or discharge summary
Enter .DME### smartphrases for each item and complete the fields
An Electronic COC is not required if DME is ordered without any Home Care
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Improve coding: ref - this was an email from AAFP

Ob Staff:
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The Clinical Approach: CS

CIPE  SND

159161   zhV-2yK-ySz-twn ref

9053067 Ironl1ght ref  Resource Page


----- Early List
1. Go to MHA Kenwood Hospitalist List
    - sort by attending
    - print
    - if the attending is a non-hospitalist, see who has the patient on our team
    - count totals for everyone including consults

Rounders:  
----------- #     
2 ----------- #
3 ----------- #
4 ----------- #
5 ----------- #
6 ----------- #
7 ----------- #
8 ----------- #
--------- Try not to add any to Middle and Lat Shift
Middle  --- #
Late      --- #
-------------  # total patients
 
2. Go to census - in this case Amit & Aliu - Blue = H&Ps to be done.
    - on the list place and X by H&Ps to be done, C by consults = # new patients
    - make sure these are allocated fairly
    - push all of Jessica's patient to me tomorrow as she is leaving
    - select entire list, right click and enter "Mha* hospitalist", click the "Attending" box, and then Accept
    --- "Mha Hospitalist" must be put on treatment team to be certain we never lose the patient
    - make the new doc the Attending AND place him on the Treatment Team along with Mha*
    --- for the previous, only make new Doc attending if taking over from night team
    - select "Past Providers"  box to see if night doc was put back as attending by EPIC after surgery.
    - Mark fixes in red on the print out

3. Now make these changes in EPIC. Mark fixes in red on the print out.

Notes: remember to assign everyone twice.
            Remove Jessica from all treatment teams: - do this at the end !
            1. select all records
            2. Rt-click "End Other's Assignments" - (person leaving, night persons)
            3. Type Jessica's name in the blank, Accept


4. Last - reorganize the list by clicking "Bed" down and "Attending" up

5. On final copy, write "consults" and "H&P" on left of line, place hospitalist's name on the right.

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VTE Rule Out
- DD cutoff 500 mcg/dl - is very poor in patients over 50.
- age-adjust with age x 10 mcg/dl
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FilmArray Respiratory Panel (Soft Code 7RSSP, Respiratory Panel, Film Array [LAB9344]) 
- Same Day Report
Adenovirus
Coronovirus 229E, HKU1, OC43, NL63
Human Metaneumovirus
Human Rhinovirus/Enterovirus
Influenza A, A/H1, A/H1-2009, A/H3, B
Parainfluenza 1,2,3,4
RSV
Bordetella Pertussis
Chlamydophila pneumoniae
Mycoplasma pneumoniae
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Very nice TIA HPI:
The patient is a 77 years old man without significant past medical history who woke up this morning around 6 AM with acute onset of right arm numbness and slurred speech. Symptoms started suddenly. He denies any headache, weakness in his arms or neck or back pain. No recent fever or chills or trauma. No prior history of stroke or TIA. He was almost back to his baseline within less than an hour. He decided to come to the hospital. In the ED, his blood pressure was elevated above 190/90. He was given blood pressure medications, aspirin and was admitted to the hospital.
Now the patient denies any other new symptoms. He denies any headache, weakness or numbness or tingling or chest pain. He denies use of drugs. No prior history of strokes. No family history of strokes. No sleep disturbance. Other review of system was unremarkable.
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Admission check list:
- PCP
- Code Status
- Anticipated D/C
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Rounding check list:
- document if pt is medically stable for discharge 
- allows for accurate tracking of avoidable days
- helps with reduction of Length of Stay
- always mark avoidable days and discharge
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Unconventional Analgesics available at MAHER
- trolamine salicylate (ASPERCREME) 10% creme
- lidocain patches
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Anticoagulation Reversal Orderset
A new orderset for anti-coagulation reversal goes into production July 7.   Below are the recommended labor orders for various anticoagulation mediation classes.

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Remember 
- always use Acute Encephalopathy instead of AMS
- always use Acute Blood Loss Anemia instead of Anemia.
- always use "I" for admission from anywhere, "C" is only for consults
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3.11.15 
Molly Montgomery B1 - nurse of the month
Chondra 90% - doc of the month
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- UpToDate.com - customize for my own CMEs
- Do - Delete smart phrases and use Bill's - call IT if needed b/c I'm owner of mine
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- ER 84083 - "Venus"
- Transfer line to another hospital (i.e. ENT, Neuro to Jewish) 981-BEDS
- What is 584-BEDS ?
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Admission Notes

-  DO the ICD Training every month

- update the treatment team when admit a patient

- document code status & advanced directive for every patient

- discharges are to be done by 11:00 (at least 50%)

- put D/C goal in DISPO line of Q note and to where

- include PCP Q pt & notify PCP of adm, discharge or status change

- give baseball cards to patients

- round w/ nurse - look up their name in the EMR

- Core Measures - AMI, CHF, CVA, SCIP, VTE and PNA - must be in chart

- Core Measures - Beth Shannon 513-624-5284

- Use admission order set within 30 minutes of being notified of an admission

- .DEMOXYGEN - use this to document need for home O2

Specialists

- Mercy Cards - Puri, Paquin, Gill, Hutchins, Gupta, Meyers, NP Cheryl Pierce

- Mercy EP - RP Singh, NP Betsy Bachelor

- Ohio Heart - Forman, Corl, Behrens, NP Joe Barone

- Mercy Pulm - Major, Ray, Parker, Beck, Ataya, Kinder

- Trihealth Pulm - Halvonik, Malik, Thorpe, Eisentrout - they manage vent, we do all else

- Mercy Gen Surg - Ward, Welshhans, Shiff, Poynter, PA Ashley Easterling

- Mt. Auburn Neph - Adhikari, Safdar

- Kidney HTN - Davis, Butt, Khalil, Lancaster

- Cinci GI - Lopez, Ionna, Krone, Kakarlapudi, Bhaskar

- Neuro - El-saad - Neuro generally goes to Jewish

- URO - Krick, Braun, Bey, Dheenan, NP Rachel Savage

- Rheum - Hiltz

- No IP consult available for ENT, Neurosurg (head), endocrine, bariatric surgery, deem

- ENT, Neuro - Jewish 

- Palliative Care - Mardee White 

General

- insulin - goto orders / type "insulin" / enter "sliding" into "Facility List"

- Use order sets for everyone: ABX, DVT, Code Status

- Blood Cx - New PCR - Mercy West- DNA detection - 12hr turn around !

- Prcedex - use for withdrawal

- When get a new arm add "Hospitalists *Mha" to tx team

- To remove us from list remove name and "MHA Hospitalists"

- Remember right click to see tx team

- Plan the dispo for all patients ASAP - think ahead

- An "X" on census = an H&P to be done

- Finish all billing daily

- Drip initial orders on new admissions ASAP

- Neal Fedders - Dir of Operations for Pt Experience

- Care Team Tab - Treatment Team

- Do what is asked on sticky notes and then delete them.

- CDS sticky notes - label done when done then sign with .esign

- Document the anticipated D/C date in SC

- All D/C summaries w/in 48 hrs

- Epic "Kenwood Hospitalists" = Master List

- My Patients - My patient list - Print it and then reconcile with the main list (Carrie's list)

- Compare printout with SoundConnect (pwd on back of badge)

Other General

- insulin - goto orders / type "insulin" / enter "sliding" into "Facility List"

- Use order sets for everyone: ABX, DVT, Code Status

- Blood Cx - New PCR - Mercy West- DNA detection - 12hr turn around !

- Prcedex - use for withdrawal

- When get a new arm add "Hospitalists *Mha" to tx team

- To remove us from list remove name and "MHA Hospitalists"

- Remember right click to see tx team

- Plan the dispo for all patients ASAP - think ahead

- An "X" on census = an H&P to be done

- Finish all billing daily

- Drip initial orders on new admissions ASAP

- Neal Fedders - Dir of Operations for Pt Experience

- Care Team Tab - Treatment Team

- Do what is asked on sticky notes and then delete them.

- CDS sticky notes - label done when done then sign with .esign

- Document the anticipated D/C date in SC

- All D/C summaries w/in 48 hrs

- Epic "Kenwood Hospitalists" = Master List

- My Patients - My patient list - Print it and then reconcile with the main list (Carrie's list)

- Compare printout with SoundConnect (pwd on back of badge)

- Drag everyone off "Nignts" to me

- Green - anticipated D/C - home in 12-36 hr

- Blue - no billing done

- Red - already billed by night team - new census today 

- Black - on svc > 1 day

- drag and drop between teams, add PCP if possible or "No PCP".

- Use order sets for everyone: ABX, DVT, Code Status

- Blood cultures - new PCR method - goes to M. West - DNA from given bacteria assessed 12hrs

- Sepsis - Focused - for folks already hospitalized

- Precedex - used for withdrawal

- .SOUNDADMISSION - Sound H&P

- .SOUNDPROGRESS

- .SOUNDCONSULT

- .SOUNDDISCHARGE

- .HDI - hospitalist discharge instructions

- 2 midnight rule - IP vs Observation - if hospitalized > 2 midnights  then call it IP

- Chest pain usu won't qualify as IP

- COPDX.com - home COPD treatment

- Update the problem list before starting the H&P

- Check active problems under "Problem List"

 

- When have red "discrepancy" flags ? 1. No billing info on the shift 2. vs versa

- Blue(6) - # patients

- Doc at top - who carried list previous day

- Print rounding list - "Home", "Print List"

- Add pt 

  - do pt & H&P

  - or pending admission

  - click "+" icon or "new stay"

  - search for patient

  - if pending admission - click "Adm Pending" - which is just putting a name on the list




 Coding and Documentation Team and Regional Compliance Specialist:


 Weight Loss MercyHealthyWeight.com 1-877-915-9062

EPIC Doc Helpline: (866) 557-9416

Payroll Julie Carter 253-284-1884
HR Kyle Johnson 253-680-6053
Credentialing Fran Johnson 817-865-3399
Work email problems: ithelpdesk@soundphysicians.com
Maria Phillips RN, BSN
Clinical IS Specialist
Mercy Health
The Jewish Hospital
Office:  (513) 686-3238
Pager:  (513) 308-8778
Fax:  (513) 686-5416
maphillips@mercy.com

Dana Fender - IT a Anderson
DXFender@mercy.com


Coding:

Difficult to code: bacteremia, hypoxia, renal insufficiency

- sepsis must be problem #1 if present on admission

- CDS notes - if u agree, docment in the body of the chart, if disagree say so in the note.

- coders do not code from the problem list

- possible diagnoses for a combative, demented person:

-- acute encephalopathy, acute confusion, dementia, other, unble to determine

- goal is to chart severity of dx adn risk of mortality.


C - inpatient consult code

E - Pts evaluated in ER and not admitted

EF -

F - inpatient follow up

I - observation status

ON - consult in OP unit (CP, pre-op) or on hospitalized pts on obs status.

P - procedures

PS - prolong stat

S - (same day admit and D/C) enter in SC if pt spends => 10hr

   - YOD - remove pt from pt list

   - YS - if pt was admitted as IP 

D - discharge services D1 < 30 min, D2 > 30 min

OD - discharge from obs status, no time requirement

X - critical care X1 - first 30-74 minutes, X2 each additional 30 minutes

   - must be documented in the medical record

   - critical services that must be billed separately:

      ETT placement 31500

      Art line placement 36620

      Central line placement 36556

      Swan-Ganz placement 93503

      CPR 92940

      EKG interpretation

Prolonged Services

- PF-1 (99356) - first 30-60 min of prolonged services

- PF-2 (99357) - each additional 30 minutes of prolonged services

- goto my site to find typical times

Y - non-billable

Xferred - ICU - ZT - patient transfer, next do choose "YN" - no charge.

Click "CPT" to link

"Provider Billing Submissions" - pull your billings

GAPS - number of days of billing missed





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Comprehensive Example:
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--- Compliant Coding Part II


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--- Patient Experience / HCAHPS

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CKD Acute / Chronic Anemia 2/2 blood loss, CKD, malignant neoplasm
CHF Acute / Chronic / Acute on Chronic (exacerbation)
- systolic (EF<40) / diastolic (echo) / both
- complications: arrhythmia, acute resp failure, acute pulm edema
- comorbidities: CAD, DM

Cardiomyopathy - hypertensive, alcoholic, sarcoid
DMII / I - controlled / uncontrolled
- complication: CKD, neuropathy
- comorbidities: 
Malnutrition - mild / moderate / severe protein-calorie
- BMI
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.mscPNA phrase:
(HA)Pneumonia, +/- POA, likely 2/2: aspiration / GNR vs G+ / pseudomonal / MRSA
- w/ w/o signs of sepsis:
- w/ w/o respiratory failure
- core measures: blood cx, abx, abx taken during past 24 hr ?

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If on O2 at home then automatically becomes chronic respiratory failure. But is not automatically chronic if only on at night.

Recall the following phrase - integrate into resp failure: 
Acute on chronic Resp Failure complicated by severe AE COPD POA
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--- Confirmed for acute resp failure
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.mscSepsis
Sepsis x/4
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Eravacycline - for CDiff, Neisesseria
--- severe sepsis
--- septic shock
--- sepsis
--- sepsis
--- sepsis
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--- sepsis
--- pna
--- pna
--- pna
--- pna
--- pna
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ĉ
Marc Curvin,
May 25, 2015, 12:20 PM
ĉ
Marc Curvin,
May 25, 2015, 12:20 PM
ĉ
Marc Curvin,
May 25, 2015, 12:20 PM
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