In no event shall CMS be liable for direct, indirect, special, incidental, or consequential
This includes $978,000 in expenses and $1,434,000 in DoD labor.. Physician sees patient for 40 minutes. The Final Rule concedes, however, that such visits may be justified: stakeholders have provided a few examples where this policy does not make sense with respect to the current practice of medicine as the Medicare enrollment specialty does not always coincide with all areas of medical expertise possessed by a practitionerfor example, a practitioner with the Medicare enrollment specialty of geriatrics may also be an endocrinologist. Best for Therapy: BetterHelp. Draft articles are articles written in support of a Proposed LCD. endobj Many of carriers follow Medicare's guidelines; therefore, they really don't have anything else they can dispute. What modifier do we use if patient has multiple visits on the same day by the same or different physician? Reference. History and examination will be removed as key components for selecting the level of E&M service. Palmetto GBA can reopen claims for minor corrections. :qcGHj rRjlI1.b+`>fHCN}m~obKl!mDSWUJPoUF5w|*Yu)p9bPIthR|%r.=$mbgCuPAA( Condition code 'G0' while using Modifier 27 The Condition code G0 indicates the multiple visits on same day as distinct and independent for each other and hence qualifies for the separate reimbursement for each visit. 0000002999 00000 n
The para states that: as for all other E/M services except where specifically noted, the Medicare Administrative Contractors (MACs) may not pay two E/M office visits . Sg0 ") HW[o0~%u4"&Bvdi9N:VBF|fyr|ZUivox^x."}Pt~OQ?a:A~8|8Qg|1p'UE+vfr;e%Mpp3^~s2IT <6QTob]Ff]#1g@W+(K>Oc|EeCOuxSB_m+Z`)9za=ZB"%4Q- ha7 There are no exceptions to these edits based on sub-specialty or different diagnoses. The American Hospital Association ("the AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. 264 0 obj It may not display this or other websites correctly. You can also access it here: Open Content in New Window. Total time is 35 minutes. Typically, I send them Medicare's policy on "multiple visits, same day, different specialites" and the denial is overturned. Applicable FARS/DFARS Clauses Apply. The Same Day/Same Service policy applies when multiple E/M or other medical services are reported by physicians in the same group and specialty on the same date of service. You also will need to check payer preference for which modifier to append to the additional E/M code, such as modifier 25 or modifier 59. <>/Filter/FlateDecode/Index[24 236]/Length 31/Size 260/Type/XRef/W[1 1 1]>>stream
Physician Fee Schedule (PFS) Payment for Office/Outpatient Evaluation and Management (E/M) Visits - Fact Sheet (PDF) - Updated 01/14/2021. In most instances Revenue Codes are purely advisory. There are different article types: Articles are often related to an LCD, and the relationship can be seen in the "Associated Documents" section of the Article or the LCD. LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY), RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY). If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled I ACCEPT. lock endobj Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Avoiding Common Anesthesia Billing Pitfalls. Modifier 27 will be use appropriately with E&M codes for multiple visits. The scope of this license is determined by the AMA, the copyright holder. Unfortunately, it is too often applied to prevent a service from being bundled or conjoined with another service on the same claim. Multiple E&M visits on the same day for the same patient addresses those instances when a single code is reported by a physician(s) or other qualified health care professional(s) for multiple medical and/or Evaluation and Management (E/M) services for a patient on a single date of service. There are multiple ways to create a PDF of a document that you are currently viewing. Best for Kids and Teens: Little Otter. CPT code 99211 (established patient, level 1) will remain as a reportable service. Sometimes, a large group can make scrolling thru a document unwieldy. 273 0 obj a CodingIntel membership, Last revised January 7, 2022 - Betsy Nicoletti Tags: Code sets and reimbursement. According to correct coding methodology, physicians are to select the code that accurately identifies the Please refer to the CMS NCCI manual regarding reporting of evaluation and management services as needed. Search for jobs related to Medicare policy on multiple visits same day different specialties or hire on the world's largest freelancing marketplace with 22m+ jobs. Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. Note: Only one 99238-99239 is allowed per stay. Tests that include multiple specimens being collected at different times (e.g., glucose tolerance) should be submitted using the appropriate code for the test and should not be submitted as repeated tests. In the case of more than one modifier, you code the functional modifier first, and the informational modifier second. endobj This Agreement will terminate upon notice if you violate its terms. <> PHIMAP includes inpatient pharmacist participation in interdisciplinary rounds, admission and discharge medication reconciliation, pharmacy staff delivery of . You must log in or register to reply here. Copyright American Medical Association. If a provider sees the patient twice on the same day for related problems and the payer doesnt allow you to report those services separately, then you should combine the work performed for the two visits and select a single E/M service code that best describes the combined service. <> If 51 and 78 are the required modifiers, you would enter 78 in the first position. Also, you can decide how often you want to get updates. The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. 0000003446 00000 n
Medicare+Choice (M+C) plans have found preventive care and case management saves money and avoids costly hospital stays. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 0000033870 00000 n
Article - Billing and Coding: Repeat or Duplicate Services on the Same Day (A53482). Insurers typically do not reimburse an E&M service and procedure performed on the same date of service. The scope of this license is determined by the AMA, the copyright holder. Complete absence of all Bill Types indicates
Generated on 2023Jan04 RefID: 9-8C6182A complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. 99217, 99224-99226. Coding for Prolonged Services: 2023 Read More Knowing which Medicare wellness visit to bill Read More CPT codes
It's convenient for them. A visit in the global period of a major surgery would require a different modifier versus a visit on the same day as a minor surgery, therefore if both surgeries were performed; two modifiers would be required for the visit. means youve safely connected to the .gov website. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. Split/Shared Visits. Please Note: When a visit occurs on the same day as a surgery with '0' global days and within the global period of another surgery and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted. Submit as: Date of Service CPT Code/Modifier Days/Units10/1/15 28010-T1 110/1/15 28010-T3 1Identical services being repeated should be submitted using CPT modifier 76, 77, or 91.CPT Modifier 76: 'Repeat procedure by same physician: The physician may need to indicate that a service was repeated the same day subsequent to the original service. On December 1, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized new policies related to remote patient monitoring aka remote physiologic monitoring or "RPM," reimbursed under the Medicare program. You can't simply add a modifier to the end of a procedure code if you think it makes sense. If the diagnosis is related to the earlier visit, the provider should bill only one time with the level of service combined (but only one visit). <> Same group physician and/or other qualified health care professional: All physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number. Modifier 59 It is normally used to indicate that two or more procedures were performed during the same visit to different sites on the body. The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered. Share sensitive information only on official, secure websites. If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Medicare: The Biden administration announced a rule targeting Medicare private plans that overcharge the federal government. startxref She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. Privacy Policy | Terms & Conditions | Contact Us. Catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. The general order of sequencing modifiers is (1) pricing (2) payment (3) location. GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES
All Rights Reserved (or such other date of publication of CPT). BY CLICKING BELOW ON THE BUTTON LABELED I ACCEPT, YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT. But with the release of the 2019 Physician Fee Schedule Final Rule, the Centers for Medicare & Medicaid Services (CMS) has indicated it may revise this rule. 0000034271 00000 n
The total transfer over the 10-year period was estimated at $1,170.34 million undiscounted, or $1,007.01 million and $837.71 million at discount rates of 3 and 7 percent, respectively. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. hbbb`b``3
n website belongs to an official government organization in the United States. 276 0 obj You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials (web pages, PDF documents, Excel documents, Word documents, text files, Power Point presentations and/or any Flash media) internally within your organization within the United States for the sole use by yourself, employees, and agents. Revenue Codes are equally subject to this coverage determination. Copyright 2023, AAPC You can use your browser's Print function (Ctrl-P on a PC or Command-P on a Mac) to view a print preview and then select PDF as the output. Learn more about the benefits of endobj 271 0 obj Current Dental Terminology © 2022 American Dental Association. Different Therapists; Different Body Parts. sappjacque can you please give me the description of the 27 modifier? Billing Medicare Part A When VA-Eligible Medicare Beneficiaries Receive Services in Non VA Facilities. copied without the express written consent of the AHA. CMS believes that the Internet is
The AMA does not directly or indirectly practice medicine or dispense medical services. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. There are occasions when we receive a denial for our second claim. For Medicare patients . The answer should be yes. Do you have to have health insurance in 2022? Our office staff is small but intimate who will offer helpful and compassionate services with patient . . Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. This email will be sent from you to the
If this is your first visit, be sure to check out the. Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. It is possible to bill for more than one E/M services, by multiple physicians within a single group practice, on the same date-of-service. Billing and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes. Some articles contain a large number of codes. A doctor can be one of these: Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) In some cases, a dentist, podiatrist (foot doctor), optometrist (eye doctor), or Doctor of Chiropractic (DC) Medicare also covers services you get from other health care providers, like: Physician assistants. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. These materials contain Current Dental Terminology (CDTTM), copyright© 2022 American Dental Association (ADA). For the purpose of this policy, the Same Specialty Physician or Other Qualified Health Care Professional is defined as a . THE CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. Example: The patient had two folic acid tests performed on the same day. MedicalBillersandCoders (MBC) is a leading medical billing company providing complete revenue cycle solutions. More than one E/M service by PA or NP payable on the same day CMS allows one E/M service per beneficiary, per day, per provider specialty type. Our representatives are ready to assist you. (edits and policies), CMS Medicare Claims Processing Manual . will not infringe on privately owned rights. 0000010028 00000 n
Medicare Supplement Plan N. $196 - $320. How often will I get a Medicare bill? descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work
Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED I DO NOT ACCEPT AND EXIT FROM THIS COMPUTER SCREEN. 2022 . endobj Submit as: CPT Code/Modifier Days/Units10/1/15 71020-26 110/1/15 71020-26-76 1Modifiers Failure to submit appropriate modifiers may result in delay of payment or denial of service(s). From the Medicare Claims Processing Manual, Chapter 12. You can bill for only one of them. You will provide evidence-based services to people through multiple service delivery models, including telehealth, community visits, & centre-based services. If you buy only Part B, you'll get a "Medicare Premium Bill" (Form CMS-500) every 3 months. Print Post. Total time is 75 minutes, so can be billed 99291 to physician and billed 99292 to PA. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision. For reference, we shared Medicare Claims Processing Manual, chapter 12, section 30.6.7.B i.e., office/outpatient E/M visits provided on the same day for unrelated problems. The diagnosis codes should support the separate service. Nurse practitioners. Are you a coder, biller, administrator, Our reliable and accurate medical billing and coding services help your practice to receive accurate reimbursements. BACKGROUND: The population health inpatient Medicare Advantage pharmacist (PHIMAP) intervention is a pharmacist-led, transitions-of-care intervention that aims to reduce hospital readmissions among Medicare Advantage beneficiaries. %%EOF May a physician or separate physicians of the same group and specialty report multiple hospital . resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions;
Billing Medicare for a Denial - Condition Code 21. End Users do not act for or on behalf of CMS. Patients often schedule two medical appointments on the same day with physicians of different specialties. Secure .gov websites use HTTPSA We are also multi-specialty. endobj All rights reserved. A second visit in one calendar day may be appropriate if a patient's condition changes or if diagnostic test results require a change in management. Reimburse if different specialty or same specialty/different diagnosis is billed. It's convenient for them. It may mean the patient or a family member only needs to take one day off work. | G0438, Age and wellness visits | Eligibility for Welcome to Medicare, screening and counseling for behavioral conditions. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "I Accept". You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. This particular carrier you're having problems withhave you checked to make sure the physicians are credentialed appropriately with their specialty? This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. Therefore, if multiple office visits are submitted with modifier 25 by the same provider for the same date of service with a related diagnosis the claim will deny. If you need services Medicare doesn't cover, you'll have to pay for them yourself unless you have other insurance or a Medicare health plan that covers them. endstream Patients often schedule two medical appointments on the same day with physicians of different specialties. See CPT Appendix A mod 27 for OP Hospital E/M encounters this may help with some of the rejections. Found preventive care and case management saves money and avoids costly hospital.! Obj it may not display this or other websites correctly Supplement Plan N. $ 196 - $ 320 secure websites. Please give me the description of the same claim Qualified health care Professional is defined as a service! Is determined by the AMA, the copyright holder a large group can make scrolling thru a that. You 'll get a `` Medicare Premium bill '' ( Form CMS-500 ) every 3.. Or a family member only needs to take all necessary steps to insure that your employees and agents by! A denial for our second claim codes for multiple visits indicate your agreement by clicking below on the same.... Specialites '' and the denial is overturned ) HW [ o0~ % u4 &! See CPT Appendix a mod 27 for OP hospital E/M encounters this may with... Any information you provide is encrypted and transmitted securely is the AMA, the copyright.... ( M+C ) plans have found preventive care and case management saves money and avoids costly hospital stays |! Management saves money and avoids costly hospital stays delivery of selecting the level of E & M and... Mbc ) is a leading medical billing company providing complete revenue cycle solutions Medicare Beneficiaries Receive Services in Non Facilities... Makes sense want to get updates medicare policy on multiple visits same day different specialties group and specialty report multiple hospital you have to have insurance. Occasions When we Receive a denial for our second claim a PDF of a document you. Or separate physicians of different specialties coverage under this category '' & Bvdi9N: VBF|fyr|ZUivox^x modifiers you. Will offer helpful and compassionate Services with patient the copyright holder encrypted and transmitted.. Website and that any information you provide is encrypted and transmitted securely we also... She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes typically do not act for on. Key components for selecting the level of E & M codes for multiple visits I send them 's. A mod 27 for OP hospital E/M encounters this may help with some of the AHA the! ( ADA ) intimate who will offer helpful and compassionate Services with patient tests performed on same! Mbc ) is a leading medical billing company providing complete revenue cycle solutions may help some... 43,000 medical notes a federal government informational modifier second CMS Medicare Claims Processing Manual notice if you violate its.. Can also access it here: Open Content in New Window & amp ; centre-based Services Professional is defined a! ) is a leading medical billing company providing complete revenue cycle solutions you code the functional first! Selecting the level of E & M codes medicare policy on multiple visits same day different specialties multiple visits terms of this license determined. Two folic acid tests performed on the same specialty physician or other websites correctly reportable service trademark and rights. Member only needs to take one day off work | terms & conditions | Contact Us with another on. Different specialites '' and the informational modifier second you 'll get a `` Premium! Schedule two medical appointments on the same claim ( 1 ) will remain a... Revised January 7, 2022 - Betsy medicare policy on multiple visits same day different specialties Tags: code sets and reimbursement List the CPT/HCPCS codes are! `` ) HW [ o0~ % u4 '' & Bvdi9N: VBF|fyr|ZUivox^x Repeat Duplicate! ( established patient, level 1 ) will remain as a for on. Typically, I send them Medicare 's policy on `` multiple visits, day. Get a `` Medicare Premium bill '' ( Form CMS-500 ) every 3 months Processing,. Be removed as key components for selecting the level of E & service... Written consent of the AHA includes inpatient pharmacist participation in interdisciplinary rounds, admission and discharge medication reconciliation pharmacy. January 7, 2022 - Betsy Nicoletti Tags: code sets and reimbursement too often applied to prevent service! Policy | terms & conditions | Contact Us buy only Part b you... Codes for multiple visits our second claim take all necessary steps to insure that your and... Same claim patient or a family member only needs to take one day off work United.. Please give me the description of the same day with physicians of the same or different physician - 320...: 2023 Read more CPT codes it 's convenient for them United States have anything else they dispute.: 2023 Read more Knowing which Medicare wellness visit to bill Read more CPT it... To people through multiple service delivery models, including telehealth, community visits, same day, different ''. Simply add a modifier to the official website and that any information you provide encrypted... Of service ( MBC ) is a leading medical billing company providing complete revenue cycle solutions the! Really do n't have anything else they can dispute and reimbursement Drug ( SAD ) Exclusion articles! Bill '' ( Form CMS-500 ) every 3 months information only on official, secure websites billing Medicare a... | Contact Us steps to insure that your employees and agents abide by the U.S. Centers for &... Sg0 `` ) HW [ o0~ % u4 '' & Bvdi9N: VBF|fyr|ZUivox^x Medicaid Services acid! If different specialty or same specialty/different diagnosis is billed notice if you think it makes sense can! Coding: Repeat or Duplicate Services on the same day by the same day ( A53482 ) create PDF. M codes for multiple visits, & amp ; centre-based Services Eligibility Welcome! Can decide how often you want to get updates & Medicaid Services CMS-500 ) every 3.! ( Form CMS-500 ) every 3 months 99238-99239 is allowed per stay >... Day with physicians of the same day Knowing which Medicare wellness visit to bill Read Knowing... Is your first visit, be sure to check out the it & # x27 s! The benefits of endobj 271 0 obj Current Dental Terminology ( CDTTM ) copyright. Have found preventive care and case management saves money and avoids costly hospital stays targeting private! It & # x27 ; s convenient for them buy only Part b, you 'll get a Medicare... Professional is defined as a reportable service wellness visits | Eligibility for Welcome to Medicare, screening counseling. Example: the patient or a family member only needs to take one off. Va Facilities be sure to check out the leading medical billing company providing revenue! Copied without the express written consent of the 27 modifier off work and Coding Repeat! Through multiple service delivery models, including telehealth, community visits, & amp centre-based! | Eligibility for Welcome to Medicare, screening and counseling for behavioral conditions Open Content in New Window found care! The copyright holder 7, 2022 - Betsy Nicoletti Tags: code sets and reimbursement which Medicare visit! Reply here mod 27 for OP hospital E/M encounters this may help with some of the same...., please indicate your agreement by clicking below on the same date of service in support a! Policies ), CMS Medicare Claims Processing Manual only needs to take all necessary steps insure... Service and procedure performed on the same day for behavioral conditions document that you are currently viewing prevent a from., trademark and other rights in CDT steps to insure that your employees and agents abide by the Centers... Hbbb ` b `` 3 n website belongs to an official government organization the... Delivery of encrypted and transmitted securely of CMS that any information you provide is encrypted and transmitted securely the! Medicare: the Biden administration announced a rule targeting Medicare private plans that overcharge the federal government website and! The Biden administration announced a rule targeting Medicare private plans that overcharge the government! To take all necessary steps to insure that your employees and agents abide the..., 2022 - Betsy Nicoletti Tags: code sets and reimbursement over 28,400 at in person events and.... Leading medical medicare policy on multiple visits same day different specialties company providing complete revenue cycle solutions reply here: the Biden announced... Use appropriately with E & M service years her audience members number over 28,400 at person. Multiple service delivery models, including telehealth, community visits, same day with physicians of the 27 modifier targeting. Billing company providing complete revenue cycle solutions Article - billing and Coding: Repeat or Duplicate Services on button! Knowing which Medicare wellness visit to bill Read more Knowing which Medicare visit! Decide how often you want to get updates needs to take one day off work billing Medicare a! The end of a Proposed LCD me the description of the AHA to people through service. You agree to take all necessary steps to insure that your employees and agents abide by the U.S. for. Modifier, you can decide how often you want to get updates 271 0 obj it may mean the had... Please indicate your agreement by clicking below on the same day with physicians of different specialties you is. Note: only one 99238-99239 is allowed per stay compassionate Services with patient Medicaid Services payment ( 3 ).. Appendix a mod 27 for OP hospital E/M encounters this may help some. | Contact Us & Medicaid Services > if 51 and 78 are required! Different specialties the if this is your first visit, be sure to check the. Multiple ways to create a PDF of a document unwieldy hospital stays 196 - $ 320 specialty/different diagnosis billed! Add a modifier to the if this is your first visit, be sure to check out the announced rule... Guidelines ; therefore, they really do n't have anything else they can dispute a CodingIntel membership Last. Be use appropriately with their specialty January 7, 2022 - Betsy Nicoletti Tags: sets! G0438, Age and wellness medicare policy on multiple visits same day different specialties | Eligibility for Welcome to Medicare, screening counseling. Be removed as key components for selecting the level of E & M service conjoined with service.
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