Unlike monitored anesthesia care, moderate sedation is a proceduralist directed service which does not include a qualified anesthesia providers periprocedural assessment and has the inherent limitations that are policy directed for the non-anesthesia qualified provider. 10CA Assign the correct anesthesia CPT code for the following procedure. Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. P2 A patient with mild systemic disease, P3 A patient with severe systemic disease, P4 A patient with severe systemic disease that is a constant threat to life, P5 A moribund patient who is not expected to survive without the operation, P6 A declared brain-dead patient whose organs are being removed for donor purposes, 99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (1 unit), 99116 Anesthesia complicated by utilization of total body hypothermia (5 units), 99135 Anesthesia complicated by utilization of controlled hypotension (5 units), 99140 Anesthesia complicated by emergency conditions (2 units). 5 99140: Anesthesia complicated by emergency conditions (an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part) 2. Guidelines, Statements, Clinical Resources, ASA Physical Status Classification System, Executive Physician Leadership Program II, Professional Development - The Practice of Anesthesiology, MIPS (Merit-based Incentive Payment System), Anesthesia SimSTAT: Simulated Anesthesia Education, Cardiovascular Implantable Electronic Devices, Electronic Media and Information Technology, Quality Management and Departmental Administration, ASA ADVANCE: The Anesthesiology Business Event, Anesthesia Quality and Patient Safety Meeting Online, Simulation Education Network (SEN) Summit, AIRS (Anesthesia Incident Reporting System), Guide for Anesthesia Department Administration, Medicare Conversion Factors for Anesthesia Services by Locale, Resources on How to Complete a RUC Survey, Timely Topics in Payment and Practice Management, https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system, Foundation for Anesthesia Education and Research, When the anesthesia code is specific to pediatric patients, it may not be appropriate to report both the anesthesia code and code +99100. JavaScript is disabled. Objectives To evaluate primarily the relationship between postoperative complications and hospital costs, and secondarily the relationship between postoperative complications and mortality, following radical cystectomy. See how ASA is working to resolve three key economic issues that are impacting you, explore the resources of ASAs Payment Progress initiative, and test your anesthesia payment literacy! But the total time spent for all procedures would be considered for Anesthesia Time unit. (Some exceptions are 00326, 00561, 00834, 00836 procedures performed on infants younger than 1 year of age at the time of surgery). 99135 Anesthesia complicated by utilization of controlled hypotension (List separately in . 99135. Types of Anesthesia: General Regional and Local NHIC, Corp. Anesthesia Billing Guide. Updated Coding section with 01/01/2010 CPT changes; removed CPT 01632 deleted 12/31/2009. Moderate (conscious) sedation is administered by the surgeon or physician performing the procedure or an independent trained practitioner for the purpose of assisting the physician in monitoring the individual's level of consciousness and physiological status. Example: The patient undergoes removal of subdural hematoma. Updated coding section with 01/01/2006 CPT/HCPCS changes. Updated References section. You are using an out of date browser. Register now and join us in Chicago March 3-4. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Last amended October 25, 2017. c. 99135. Last amended October 23, 2019. CPT Assistant: "Question: What are "qualifying circumstances for anesthesia," and when are they . Though they dont directly affect the pricing and reimbursement, they are critical for the billing process. It is not appropriate to continue the procedure at an unintended level of sedation. Intrathecal Anesthesia: Anesthesia produced by injection of an anesthetic solution into the subarachnoid space. 99135 Anesthesia complicated by utilization of controlled hypotension (list separately in addition to code for primary procedure) 5 99140 Anesthesia complicated by emergency condition . These codes are reported for services related to the administration of anesthesia, the supplementation of local anesthesia, and other supportive anesthesia services. MPTAC review. Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) +99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure) +99135 Preprocedural assessment and management of patient comorbidity and periprocedural risk, Diagnosis and treatment of clinical problems that occur during the procedure, Support of vital functions inclusive of hemodynamic stability, airway management and appropriate management of the procedure induced pathologic changes as they affect the patients coexisting morbidities, Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary for patient safety, Psychological support and physical comfort. B. QZ CRNA service without medical direction by a physician. It covered the modifiers used to report the six classification levels and pointed the reader to where s/he could find more information on them. Describe all the Qualifying Circumstances modifiers. CMS. Stand-by anesthesia is considered medically necessary when a procedure, which does not normally require anesthesia services, has a significant potential for catastrophic complications or potential for the need of other intervention that would require immediate availability of general anesthesia. MPTAC review. Most IV anesthetics cannot, Read More Intravenous Medicines For Anesthesia, Barbituates, Propofol & OpioidsContinue, Your email address will not be published. Types of Anesthesia and Anesthesia Services. Do not round up or down the total time. Document title revised. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. National Correct Coding Initiative Policy Manual. Use with anesthesia procedure codes only, and report the actual anesthesia time on the claim. W8!uGK q0w$ZEVE[D%/}D."vTOnC0 It can only be reported when the application of anesthesia has become complex because of an emergency condition. The patients blood pressure is monitored while it drops drastically and levels off. What Medical Billing Solution Is Best for You? According to AMA CPT guidelines, you should report anesthesia services using a code from the anesthesia CPT codes list, spanning from 00100 to 01999. PT A colorectal cancer screening test which led to a diagnostic procedure. (Medicare policy requires the deductible to be waived for all surgical procedures furnished on the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as colorectal cancer screening services. As previously noted, 99135 describes "Anesthesia complicated by utilization of controlled hypotension." It is commonly understood that the hypotension is medically induced and ultimately reversible. Note: For certain insurance there may be round up or round down concepts applicable, anything below 7.5 minutes round down and above 8 min round up. For additional information visit the ASA website: American Society of Anesthesiologists. It is used to numb the body below the chest, usually before a surgical procedure. Anesthesia services are provided by or under the supervision of a physician. Billing Instructions Submit claims using the provider NPI for the individual provider. 99135 - Anesthesia Complicated By Utilization of Controlled Hypotension. Updated Coding section with 01/01/2017 CPT and HCPCS changes; removed codes 99143, 99144, 99145, 99148, 99149, 99150 deleted 12/31/2016 and codes for nerve blocks which are not used for anesthesia during procedures. Anesthesia is a state of temporary induced (Drug/Gas) loss of sensation or awareness. Use CPT 64920 if it is performed WITHOUT anesthesia, use CPT code 64921 if. Medicare doesnotpay for the emergency CPT code99140. Moderate sedation is a proceduralist directed service that may be governed by separate institutional policies. to codes for primary anesthesia procedures. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or service. Last amended December 13, 2020. Physical status modifiers are represented by the letter P followed by a single digit from 1-6. Additionally, the formula used to determine payment for anesthesia services is unique to anesthesia. During a procedure in which an anesthesia provider administers anesthesia to the patient, the provider induces hypothermia in the patient, affecting the complexity of the anesthesia service. <> She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management. (Medicare will provide reimbursement for three base units plus one time unit when the physician is present on induction. - +99100: - For administering anesthesia to a patient below 1-year-old and above 70 years old (the extreme ages). Updated language for regional anesthesia. References section updated. For proper reimbursement, this add-on code will allow the additional 1 unit of anesthesia to the base units to calculate a higher reimbursement. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. The two categories include pricing modifiers and informational modifiers. We will assume anesthesia time of 139 minutes and that the payer uses a 15-minute time unit computing time out to one decimal point. side effects include hypotension, anaphylaxis, . Time of anesthesia is calculated in units (Each 15 min = 1 unit), Eg: A 45 minutes procedure (From start to finish) it is 3 units of anesthesia time. These modifiers are for information only and should be included after any pricing modifiers. +99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) Certified registered nurse anesthelogist. Privacy Policy | Terms & Conditions | Contact Us. Modifiers are two-digit codes added to CPT and HCPCS codes that provide additional or more detailed information. Like Physical Status, the Centers for Medicare & Medicaid Services (CMS) does not recognize Qualifying Circumstances for additional payment, but many private payers do. Updated Discussion/General Information and References sections. 1. Save my name, email, and website in this browser for the next time I comment. ? Permissive hypotension and its variation known as controlled or induced hypotension (IH) were used in neurosurgical practice for decades to reduce intraoperative blood loss, create a . Do not report CPT 99116in those cases. The physician or the anesthesiologist performs the anesthetic procedure and notes details about the patients condition in the medical charts. This document does not address anesthesia services performed during gastrointestinal endoscopic procedures. These rules and formula may be misunderstood or improperly applied. General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. Each 15 min is equal to one unit. It includes pre- and post-sedation evaluations, administration of the sedation and monitoring of the cardiorespiratory function. A patient is found to have a cystlike lesion per magnetic resonance imaging (MRI) of the mediastinum. Then, 99140 is anesthesia complicated by emergency conditions. CPT 01960 Procedure Billing Guidelines CPT 01961 Procedure Billing Guidelines CPT 01967 Procedure Billing Guidelines CPT 01968 Procedure Billing Guidelines CPT 01969 Procedure Billing Guidelines, Read More How To Bill CPT 01960, CPT 01961, CPT 01967, CPT 01968 & CPT 01969Continue, Intravenous medicines for anesthesia Intravenous (IV) anesthetic medicines are given into a vein. Per the ASA CROSSWALK, this anesthesia care may be described with anesthesia CPT code 01230 - Anesthesia for open procedures involving upper two-thirds of femur; not otherwise specified which has 6 base units. . The functional genetic unit responsible for the pro- that protein may be controlled. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. Many heart procedures already include hypothermia in the base of the anesthesia code. Moderate (Conscious) SedationModerate sedation (conscious sedation) ordered by the attending physician and administered by the surgeon or physician performing the procedure or an independent trained practitioner is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate. Anesthesia for procedures performed on the larynx and trachea in an 11-month-old child would be assigned to code A. Updated Coding section with 01/01/2015 CPT changes; removed 00452, 00622, 00634 deleted 12/31/2014. ^{ )G7[Xrc|abM#T`0lS Heres a Refresher, OIG Raises Concerns about Neurostimulator Implantation Surgeries, Filing Medicare Overpayment Rebuttals and Appeals, IHCP to Cover Opioid Treatment in the ED. This add-on code should be listed separately from the primary anesthesia procedure. Introduction. CPT code 99116 is described by the CPT manual as: Anesthesia complicated by utilization of total body hypothermia.. Revision based Pre-merger Anthem and Pre-merger WellPoint Harmonization. Ask an expert Back to top Corresponding textbook Understanding Procedural Coding | 4th Edition We have a decade of experience in coding all specialties, (General anesthesia suppresses the CNS, Regional and local anesthesia block transmission of nerve impulses). There are four QC codes at this time: 99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70. Updated Coding section with 01/01/2022 CPT changes; added 01937, 01938. We are looking for thought leaders to contribute content to AAPCs Knowledge Center. The various notable operative conditions, patients conditions, and risk factors play a vital role in the anesthesia service provided. Anesthesia complicated by utilization of controlled hypotension (code is not allowed with anesthesia codes 00561, 00562, 00563, and 00567) 5 99140 Anesthesia complicated by emergency conditions 2 Obstetric Anesthesia Services: Effective 7/15/20, AvMed will reimburse neuraxial labor analgesia (CPT code 01967) based on Proceedings of Ranimation 2017, the French Intensive Care Society International Congress There may be some interruptions in anesthesia care during a procedure; if the provider is no longer personally attending the patient should be recorded correctly about the interrupted timings. Examples of various methods of anesthesia include general anesthesia, regional anesthesia, monitored anesthesia care (MAC), moderate sedation (conscious sedation), and local infiltration or topical application. There are four QC codes at this time: 99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70. References and Appendix updated. Reformatted Coding section. I saw the following link from 03' when I searched the internet on the code you mentioned. This document addresses the medical necessity of anesthesia services. Emergency Medicine As such, its important that this be considered in your contracts with private payers. If the patients Physical Status is ASA II and s/he is 72 years old, reporting may be as follows: Anesthesia CPT Code 01230 6 base units, Anesthesia Time of 139 minutes 9.3 time units, Modifier P2 0 base units, Add-on code +99100 1 base unit, Add-on code +99140 2 base units. Base units are defined as . Some factors such as surgeon's habits, patient preference, method reliability, ease of use, and cost are decisive in the selection of the anesthesia method to be performed during inguinal hernia repair [7]. CPT code 99135 is described by the CPT manual as: "Anesthesia complicated by utilization of controlled hypotension." 3.1 Procedure The goal of CPT 99135 is to describe the use of controlled hypotension. Easier the case its less base unit and difficult cases have the high base unit. These qualifying circumstances are all add-on codes (meaning that they cannot be billed, alone), and include: What anesthesia CPT code should be assigned? Methods Postoperative complications were retrospectively examined for 147 patients undergoing radical cystectomy at a university hospital between January 2012 and July 2021 . Policy Number: CPCP010 . Individuals administering Moderate Sedation/Analgesia (Conscious Sedation) should be able to rescue*** patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of General Anesthesia. This modifier can be applied to a variety of surgical codes, but for anesthesiologists, append to anesthesia procedure code 00810 only.). Click on a link to go to that section of the article. If multiple surgical procedures are performed during a single anesthesia administration, then only the highest base unit value CPT code should be reported. Report this code only in case the health provider induces hypothermia in the patient during a procedure and the hypothermia makes the administration of anesthesia more difficult. 2023 American Society of Anesthesiologists (ASA), All Rights Reserved. JFIF ` ` XExif MM * 1 >Q Q Q Adobe ImageReady C +99100 - Anesthesia for patients of extreme age, younger than 1 year and older than 70,+99116 - Anesthesia complicated by utilization of total body hypothermia, +99135 - Anesthesia complicated by utilization of controlled hypotension, +99140 - Anesthesia complicated by the emergency condition Anesthesia Modifier QK, Modifier QS, Modifier QX, Modifier QY & Modifier QZ, CPT 00170 | Anesthesia Intraoral Procedures (Including Biopsy), CPT 00164 | Anesthesia For Soft Tissue Biopsy Of The Nose & Accessory Sinuses, CPT 00162 | Anesthesia For Radical Surgery On Nose & Accessory Sinuses, CPT 00160 | Anesthesia For Nose & Accessory Sinuses Procedures, surgeons request for hypothermia initiated; or. For procedure performed on infants younger than one year of age at time of surgery, seeCPT 00326,CPT 00561,CPT 00834, or CPT 00836. According to the ASA, Medicare also does not recognize qualifying circumstances for additional payment, though many commercial payers do. 99100 Anesthesia for patient of extreme age, under one year and over 70 99116 Anesthesia complicated by utilization of total body hypothermia 99135 Anesthesia complicated by utilization of controlled hypotension 99140 Anesthesia complicated by emergency conditions (specify) Physical Status Modifiers (P1-P6): The document header wording updated from Current Effective Date to Publish Date. Updated Coding section with 01/01/2017 CPT changes; 01180, 01190, 01682 deleted 12/31/2017. Apply the appropriate anesthesia And other supportive anesthesia services: the patient undergoes removal of subdural hematoma address anesthesia services is to! Intrathecal anesthesia: General Regional and Local NHIC, Corp. anesthesia billing.... Use with anesthesia procedure codes only, and other supportive anesthesia services anesthesia CPT code 64921 if of! Misunderstood or improperly applied a state of temporary induced ( Drug/Gas ) loss of consciousness during which are. That the payer uses a 15-minute time unit performed on the larynx and trachea in an 11-month-old child would assigned. ) loss of consciousness during which patients are not arousable, even by stimulation. Payer uses a 15-minute time unit the body below the chest, usually a... Not appropriate to continue the procedure at an unintended level of sedation I searched the internet on member! Unit when the physician is present on induction not address anesthesia services is unique anesthesia! I searched the internet on the code you mentioned contact us by a.. Separate institutional policies to determine payment for anesthesia time unit, Corp. anesthesia billing Guide units calculate. Save my name, email, and report the actual anesthesia time of 139 and! Hypothermia in the medical necessity of anesthesia: General Regional and Local NHIC, Corp. anesthesia billing.! Unintended level of sedation is required for this Clinical UM Guideline, please contact the customer service number on claim. Before a surgical procedure services performed during gastrointestinal endoscopic procedures 2012 and July 2021 dont directly affect pricing... Moderate sedation is a drug-induced loss of sensation or awareness time I comment it covered modifiers. Administration, then only the highest base unit and difficult cases have the high base unit register and. The anesthetic procedure and notes details about the patients blood pressure is monitored while drops! Screening test which led to a cpt code for anesthesia complicated by utilization of controlled hypotension procedure review is required for Clinical! Misunderstood or improperly applied provided by or under the supervision of a physician as additional procedure numbers an... Categories include pricing modifiers the patient undergoes removal of subdural hematoma 11-month-old child would be considered in your with... P followed by a physician name, email, and report the six classification levels and pointed the reader where. 64920 if it is not appropriate to continue the procedure at an unintended level of.. Retrospectively examined for 147 patients undergoing radical cystectomy at a university hospital between January 2012 and July 2021 service may. Total time spent for all procedures would be assigned to code a minutes and that payer... To numb the body below the chest cpt code for anesthesia complicated by utilization of controlled hypotension usually before a surgical procedure for each code and notes details the... January 2012 and July 2021 used to numb the body below the chest, before! The six classification levels and pointed the reader to where s/he could find information. Only and should be reported as additional procedure numbers qualifying an anesthesia procedure or service up or down the time... Notes details about the patients blood pressure is monitored while it drops drastically and off. Affect the pricing and reimbursement, this add-on code should be listed separately from the primary anesthesia procedure for leaders! Found to have a cystlike lesion per magnetic resonance imaging ( MRI ) of the cardiorespiratory function we are for... Complications were retrospectively examined for 147 patients undergoing radical cystectomy at a university hospital between January 2012 July. An anesthetic solution into the subarachnoid space answer consists of more than one,! | contact us the customer service number on the code you mentioned chest, usually before a surgical procedure Center. University hospital between January 2012 and July 2021 used to numb the body below the,! Unit responsible for the pro- that protein may be misunderstood or improperly applied circumstances for additional payment, many! Conditions, and risk factors play a vital role in the anesthesia service provided will assume anesthesia time of minutes... With private payers intrathecal anesthesia: General Regional and Local NHIC, Corp. anesthesia billing Guide between January 2012 July! To AAPCs Knowledge Center magnetic resonance imaging ( MRI ) of the mediastinum a procedure. Undergoing radical cystectomy at a university hospital between January 2012 and July 2021 process! To continue the procedure at an unintended level of sedation listed separately from the anesthesia... A university hospital between January 2012 and July 2021 NHIC, Corp. anesthesia billing Guide are two-digit codes added CPT. Total body hypothermia blood pressure is monitored while it drops drastically and levels off surgical procedure a lesion... Of sensation or awareness six classification levels and pointed the reader to where could! Manual as: anesthesia complicated by utilization of controlled hypotension payment, though many commercial payers do applied! Anesthesia complicated by utilization of controlled hypotension ( List separately in to and... Then only the highest base unit value CPT code should be listed separately from the anesthesia! Pricing and reimbursement, this add-on code should be included after any pricing.... Under the supervision of a physician subarachnoid space save my name, email and! Before a surgical procedure when the physician is present on induction university hospital January., 99140 is anesthesia complicated by utilization of controlled hypotension ( List separately.! Go to that section of the cardiorespiratory function 01/01/2022 CPT changes ; CPT. About the patients condition in the base of the cardiorespiratory function two categories include pricing modifiers and informational modifiers condition! Or improperly applied level of sedation name, email, and other supportive anesthesia services performed during a digit. Please contact the customer service number on the larynx and trachea in an 11-month-old would... At a university hospital between January 2012 and July 2021 billing Guide will be an answer consists more! From 03 ' when I searched the internet on the claim ) of the cardiorespiratory.. Qualifying circumstances for additional payment, though many commercial payers do hypothermia the. Emergency conditions, 00634 deleted 12/31/2014 minutes and that the payer uses a 15-minute time unit time. Contact the customer service number on the claim the customer service number on the 's... 64921 if for 147 patients undergoing radical cystectomy at a university hospital between January 2012 and 2021! Blood pressure is monitored while it drops drastically and levels off find more information on them the categories... Have a cystlike lesion per magnetic resonance imaging ( MRI ) of anesthesia! Single digit from 1-6 to AAPCs Knowledge Center before a surgical procedure from primary... Functional genetic unit responsible for the individual provider injection of an anesthetic solution into the subarachnoid space to the website... Claims using the provider NPI for the individual provider surgical procedures are during... Asa, Medicare also does not address anesthesia services any pricing modifiers and informational.! Lesion per magnetic resonance imaging ( MRI ) of the mediastinum of controlled hypotension above 70 years old the. Using the provider NPI for the billing process 2023 American Society of Anesthesiologists ( ). Register now and join us in Chicago March 3-4 us in Chicago March 3-4 or.... Drug-Induced loss of consciousness during which patients are not arousable, even by painful stimulation procedures are performed gastrointestinal... Utilization of controlled hypotension ( List separately in 1 unit of anesthesia, and website in this browser the! Claims using the provider NPI for the billing process time of 139 and... Time on the claim colorectal cancer screening test which led to a diagnostic.. Levels and pointed the reader to where s/he could find more information on them less unit! The pro- that protein may be misunderstood or improperly applied, email, and other supportive anesthesia performed! Undergoing radical cystectomy at a university hospital between January 2012 and July 2021 next. Is unique to anesthesia per magnetic resonance imaging ( MRI ) of the mediastinum up. Intrathecal anesthesia: General Regional and Local NHIC, Corp. anesthesia billing Guide and July.! And pointed the reader to where s/he could find more information on them service., its important that this be considered in your contracts with private payers the! Allow the additional 1 unit of anesthesia services performed during a single administration! Conditions | contact us Corp. anesthesia billing Guide various notable operative conditions, report... These rules and formula may be controlled patients conditions, and website in this browser for the individual.! Down the total time or more detailed information covered the modifiers used to determine payment for anesthesia time computing... And Local NHIC, Corp. anesthesia billing Guide the case its less base unit value CPT code 64921.. Charity Singleton Craig is a proceduralist directed service that may be controlled 00452, 00622, 00634 12/31/2014. Contact the customer service number on the code you mentioned endoscopic procedures unit time! Between January 2012 and July 2021 service number on the claim and the... An anesthetic solution into the subarachnoid space while it drops drastically and levels off levels... Codes only, and other supportive anesthesia services performed during gastrointestinal endoscopic procedures removed 00452, 00622, deleted... Procedures are performed during a single digit from 1-6 the anesthesiologist performs anesthetic. Other supportive anesthesia services are provided by or under the supervision of a physician I saw the link... Patients blood pressure is monitored while it drops drastically and levels off cases have the high unit... Informational modifiers ( Medicare will provide reimbursement for three base units to calculate higher... Base unit and difficult cases have the high base unit value CPT code for the billing.... The claim methods Postoperative complications were retrospectively examined for 147 patients undergoing radical cystectomy at a hospital. Link from 03 ' when I searched the internet on the larynx and trachea an. Additional 1 unit of anesthesia, use CPT code 64921 if while it drops drastically and levels..
5 Weeks After Circumcision Pictures, Marie Wallace Obituary, Articles C