0000263069 00000 n Because imaging guidance is performed, be sure the ultrasound, CT, or MRI tech does not charge a guidance code when the access uses one of these imaging guidance modalities. Another example is when gastric contents have leaked and there is maceration, ulceration, or necrosis of the surrounding skin that requires debridement and management of a larger-than-normal gastrostomy tract for tube replacement. Type II Add-on codes do not have a defined set of primary procedure codes identified by AMA CPT. Code 47490 describes insertion of "tube into . Bookshelf An official website of the United States government. HHS Vulnerability Disclosure, Help We included six trials randomising 359 participants, 178 to T-tube drainage and 181 to primary closure. 58571 Total Laparoscopic hysterectomy with tubes/ovaries, uterus < 250g . Excluding the 2 patients who died, the average hospital stay for the cholecystostomy procedure was 9.8 days (range, 1-21 days). and transmitted securely. The gallbladder fluid will drain outside your body into a collection bag. It also provides access for diagnostic cholangiography.4. Accessibility This month, well discuss the major changes in percutaneous biliary interventional coding. Best answers. Han SP. In March, we covered urinary intervention. He developed bilateral pleural effusions and had a right-sided thoracocentesis performed. As the patient was septic and high risk for cardiac complications, he underwent placement of percutaneous cholecystostomy tube by IR. It also provides access for diagnostic cholangiography. 4. Procedure: Laparoscopic cholecystectomy with drain insertion. 47533 describes the initial placement of a percutaneous external biliary drainage catheter via a new access, and includes diagnostic imaging 47532. The authors concluded that laparoscopic cholecystectomy can be performed as true outpatients within hours of completion of the procedure. This will drain blocked and infected gallbladder fluid. [QUOTE="darshimatsu@yahoo.com, post: 232786, member: 188992"]what CPT should be used for a CT guided cholecystostomy tube placement? Here we present 2 cases where LC tube placement was performed in severe cholecystitis, and a subsequent interval laparoscopic cholecystectomy was performed. Heres what you need to know to be sure your coding is current and correct. Although the wRVUs for 47562 and 47563 do not reflect the RUC review of survey data and RUC recommendation, their work RVUs are correctly ranked. Intraoperatively there was evidence of acute gangrenous cholecystitis with a lot of dense thick adhesions around the gallbladder. 0000092286 00000 n 47539 describes the placement of a completely internal stent via a new access without leaving a biliary catheter at the end of the procedure. Drainage is coded for both diagnostic and therapeutic drainage procedures. JavaScript is disabled. The authors have no conflicts of interest to declare. Heres a rundown of how to apply the new codes. 0000009381 00000 n It is performed under x-ray or ultrasound. Based on a work at https://medcraveonline.com Contact Us, 2014-2023 MedCrave Group. doi: 10.1097/SLE.0000000000000217. Diagnostic cholangiogram is performed (47531), demonstrating a distal common bile duct stenosis. endstream endobj 538 0 obj <> endobj 539 0 obj <> endobj 540 0 obj <> endobj 541 0 obj <> endobj 542 0 obj <> endobj 543 0 obj <> endobj 544 0 obj [/DeviceN[/Cyan/Magenta/Yellow]/DeviceCMYK 582 0 R 584 0 R] endobj 545 0 obj [/Indexed/DeviceCMYK 179 585 0 R] endobj 546 0 obj [/Indexed/DeviceCMYK 119 586 0 R] endobj 547 0 obj [/Indexed/DeviceCMYK 231 587 0 R] endobj 548 0 obj [/Indexed/DeviceCMYK 250 588 0 R] endobj 549 0 obj [/Indexed/DeviceCMYK 74 589 0 R] endobj 550 0 obj [/Indexed/DeviceCMYK 74 590 0 R] endobj 551 0 obj <> endobj 552 0 obj <> endobj 553 0 obj <> endobj 554 0 obj [573 0 R] endobj 555 0 obj <>stream If this is your first visit, be sure to check out the. The biliary system is divided into right- and left-sided bile ducts; however, these ducts divide further into multiple smaller branches that may be individually accessed and drained, depending on the pathology treated (e.g., Klatskin tumor is a cholangiocarcinoma that has involved and caused bifurcation occlusions of the common bile duct. 0000196901 00000 n Thread . 42330. 0000304051 00000 n Patient was discharged home the same day. Laparoscopic Tube Cholecystostomy: Still Useful in the Management of Complicated Acute Cholecystitis. The advent of laparoscopic cholecystectomy began in the early 1990s, where initially there was a higher risk of conversion to open procedures due to some of the challenges encountered during surgery-between 5 and 10% rate of conversion. J Laparoendosc Adv Surg Tech A. The first endoscopic cholecystostomy was . The radiologist will create a new access into a bile duct and advance a wire and small catheter across the biliary system and ampulla into the small intestine. In these cases, replacement of the G-tube is straightforward and would be reported with code 43762, CPT Assistantcontinues, and provides the following example: A 76-year-old female suffering from significant malnutrition previously required placement of a percutaneous gastrostomy tube. A laparoscope is a long tube having a mounted camera for internal imaging that helps to place the . Outpatient procedure costs include the hospital payment for all lines on the outpatient claim for the surgery. 47535 Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation Cholangioplasty is performed (+47542). A brush biopsy followed by alligator forceps biopsy are performed and sent for pathology (+47543). 0000262177 00000 n No Intervention: no drain insertion. Am J Surg. Since the development of this procedure, multiple alternatives have been developed, including the Chait cecostomy tube. Appendectomy or laparoscopic appendectomy CPT code(s): 44950, 44955, 44960, 44970 Cholecystectomy or laparoscopic cholecystectomy, Cholecystectomy or laparoscopic cholecystectomy CPT code(s): 47562, 47563, 47564, 47600, 47605, 47610, 47612, 47620. Percutaneous placement of cholecystostomy drain has been used in . If this is your first visit, be sure to check out the. The CPT code is 47564. A 2018 study demonstrated no difference in mortality between percutaneous . 0000011118 00000 n Offer. Laparoscopic cholecystectomy ICD 10 is minimally invasive. 40500. +47543 describes an endoluminal biopsy (brush, needle, or alligator forceps) of the biliary ductal system (common bile duct, intrahepatic bile ducts). ICD 10 Code For Renal Cyst . The cholangiogram codes may be used as a base code for +47542, +47543, and +47544, but only if a catheter is not placed, replaced, or converted. Laparoscopic cecostomy button placement for the management of fecal incontinence in children with Hirschsprung's disease and anorectal anomalies. 0000277292 00000 n 1133- Budapest. The procedure was started laparoscopically in 16 and open in 8 patients. In addition, CPT codes 47562 and 47563 describe more complex surgical procedures that have a 090-day global period compared with 47560 which has a 000-day global period. National Library of Medicine 47538 Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation, each stent; existing access Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. 0000102401 00000 n Tower 1, Capital Square, Vci t 76. What is a cholecystostomy tube? Two stent codes can be submitted when double-barrel, or side-by-side, stents are placed for the treatment of a single stenosis (usually in the common bile duct from two approaches), when two separate accesses are used to place two stents, and when two stents are placed into two bile ducts for treatment of two separate stenoses. 0000196808 00000 n 0000262962 00000 n Initial Biliary Stent Placements CPT 2016:Percutaneous Biliary Interventional Coding, Tech & Innovation in Healthcare eNewsletter, Capture the Complete Clinical Picture With Precision, Applying RVUs to Pharmacists Patient Care Services, Three Tidbits Help You Code Lesion Biopsy and Removal, Consider All Factors when Coding Colonoscopies, Mohs Micrographic Surgery for Clear Coding, Members Tip: Pain-free Coding of Mortons Neuroma. Save my name, email, and website in this browser for the next time I comment. Readmission rates range from 0-8%; common causes for readmission after same day discharge include pain, intra-abdominal fluid collections, bile leaks, and bile duct stones (Sherigar, et al. CPT Code For Laparoscopic Cholecystectomy With Firefly Firefly is used to inject a dye named ICG (Indocyanine green) before . sharing sensitive information, make sure youre on a federal 0000266148 00000 n Additionally, CPT code 47563 was reviewed in October 2010. H\0s^[[ We report three patients with acute . The external biliary catheter is removed over a wire and an internal/external catheter is advanced with the distal tip in the small intestine and secured in position (Add 47535 for the conversion of an external catheter to an internal/external catheter. For all other claims, report the appropriate CPT code for laparoscopy, surgical; cholecystectomy (any method), and the appropriate CPT code for laparoscopy, surgical: cholecystectomy with cholangiography. If multiple bile ducts are biopsied, do not report additional procedure codes because all ducts biopsied are described by using this single code. 0 This procedure may be reported with new codes for tube check (47531), tube change (47536), tube removal (47537), and stone extraction (47544). 0000010573 00000 n Privacy Policy | Terms & Conditions | Contact Us. 0000262855 00000 n In the drain insertion group, investigators use the closed suction drain through a lateral 5-mm trocar and placed it in right subhepatic space. To determine long-term clinical outcomes following percutaneous cholecystostomy tube (PCT) placement. Surgical procedures StatisticsThe goal of the surgical cross-over exhibits was to identify total volume, spending, price per procedure, and differences in cost across settings of care for procedures that can be performed either in hospital inpatient or hospital outpatient settings. For 2019, the CPT codebook made changes that affect proper coding for replacement or change of a gastrostomy tube. 0000011897 00000 n Forty-four patients had the PCT removed and were managed non-operatively (30.1%) of which 5 developed recurrent . 0000008395 00000 n 0000006018 00000 n Laparoscopic tube cholecystostomy remains an alternative to open surgery in cases where the gallbladder is judged too inflamed to allow for laparoscopic removal and in cases where the patient is too sick to tolerate a more extensive procedure. A total of eight patients were admitted to the hospital following postanesthesia care, six of these eight patients were discharged on the first postoperative day. An official website of the United States government. The codes differentiate existing access from new access: Do not use this code when a balloon catheter is used for stone extraction. sharing sensitive information, make sure youre on a federal Laparoscopic cholecystostomy tube placement can be a useful adjunct in situations where there is severe acute inflammation of the gallbladder and can avoid conversion to open procedure. Submit 47533 once for each external biliary drainage catheter placed via a new access at the same session. FOIA All three codes include an initial cholangiogram (47532, 47531) and all imaging guidance (e.g., fluoroscopy, ultrasound, CT, MRI). I think you would have to use CPT 47579 Unlisted lap procedure biliary tract. A 12 French Foley catheter was inserted through one of the 5 mm port sites and placed into the fundus of the gallbladder. In such situations, the tract may be difficult to access and require dilation and guidewires to place a new tube. Unable to load your collection due to an error, Unable to load your delegates due to an error. 0000278194 00000 n The procedure of gall bladder removal and Cholecystostomy removal can be performed side by side with the help of laparoscope computer imaging. Submit 47535 once for each biliary catheter conversion at the same session. Materials. The gastrostomy catheter has become clogged; attempts to establish luminal patency have been unsuccessful. Over the last 3 decades, the laparoscopic skill of the surgeons has been much more widely adopted and the conversion rate is much lower. The incision . This is the American ICD-10-CM version of K91.5 - other international versions of ICD-10 K91.5 may differ. CPT Code For Laparoscopic Cholecystectomy With Firefly Firefly is used to inject a dye named ICG . Any member who underwent an appendectomy or cholecystectomy (laparoscopic or other) during the 365 day period ending 30 days prior to the end of the measurement year. Three patients (20%) were admitted to the intensive care unit. 2524 N. Broadway Edmond Oklahoma 73034. if you have Dr. Z's interventional book, it tells you to use abcess codes 49424,76080,49423 & 75984 for tube check and change of cholecystostomy tube if the the tube was originally placed for infection drainage. Please help me with the coding of this procedure. Here, we present our technique for laparoscopic cecostomy tube placement. The opportunity for coding specificity has never been better. Masaya Yamoto, Naoto Urushihara, Koji Fukumoto, et al. 0000024855 00000 n 0000232694 00000 n J Pediatr Surg. October 2015 . )GxGxGxGxGxGCa Here's what you need to know to be sure your coding is current and correct. Bookshelf This allows for performing interval laparoscopic cholecystectomy in a safe manner. He was initially admitted to the ICU and placed on intravenous inotropic support. The objective of the present study was to investigate the feasibility of laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting . 0000009762 00000 n Open Access by MedCrave Group is licensed under a Creative Commons Attribution 4.0 International License. In the Unites States, 90% are performed laparoscopically. Indications for and timing of PCT placement are covered, using the 2018 Tokyo Guidelines to stratify patients. Additionally, the CMDs may have looked at the CY2012 PFS where 47562 (Laparoscopy, surgical; cholecystectomy) and 47563 (Laparoscopy, surgical; cholecystectomy withcholangiography) were incorrectly ranked. May 16, 2013. 0000264613 00000 n A JP drain was inserted adjacent to it in the gallbladder fossa. Twelve biliary CPT codes were deleted for 2016 (47500, 47505, 47510, 47511, 47525, 47530, 47630, 74305, 74320, 74327, 75980, and 75982), and five previously recommended endoscopic codes (47552, 47553, 47554, 47555, and 47556) should no longer be used for percutaneous procedures because new codes more accurately describe these procedures. In 1999, Lillemoe, et al. The median timing of cholecystectomy was 47 days (range, 4-346 days). Percutaneous cholecystostomy is the image-guided placement of a drainage catheter into the gallbladder lumen. 0000265361 00000 n 0000265038 00000 n 47539 new access, without placement of separate biliary drainage catheter 0000267926 00000 n 0000102023 00000 n Roughly 2 weeks later, a cholangiogram can be performed by introducing contrast through the cholecystostomy tube. Do not submit 47541 when a pre-existing catheter is accessed to perform the rendezvous procedure. Around this time, his IR cholecystostomy drain fell out, and his liver function tests started to trend up - suggestive of ongoing acute on chronic cholecystitis. Before What is the difference between code 47490 and 47533 what distinguishes them apart. Copyright 2023, AAPC Hence IR could not reposition the percutaneous drain. Malone Antegrade Continence Enemas vs. Cecostomy vs. Transanal Irrigation-What Is New and How Do We Counsel Our Patients. This means that a small incision is made in the abdomen. 0000013171 00000 n 0000010737 00000 n 0000025038 00000 n 0000214917 00000 n 0000266889 00000 n He was therefore taken to the operating room for planned laparoscopic cholecystectomy, after his acute medical condition was stabilized. For inpatient claims, report the diagnosis code for laparoscopic cholecystectomy. At this point it was decided to perform LC tube placement in order to avoid injury to the vital structures. 0000207672 00000 n Unauthorized use of these marks is strictly prohibited. A child code below 51.0 with greater detail should be used. Laparoscopic cholecystectomy procedures without common bile duct exploration (CBDE) typically map to MS-DRGs 417-419. . Uchiyama K, Tani M, Kawai M, et al. Ask your physician what to compare it to. MeSH 2006). Specimen: gallbladder fluid sent for culture. doi: 10.1016/j.suc.2008.07.005. . 0000004444 00000 n The site is secure. The doctor usually removes the tube in about two to three weeks, after ensuring there is no further leakage. 0000010523 00000 n For 2019, the CPT codebook made changes that affect proper coding for replacement or change of a gastrostomy tube. Dr. Z is Board Certified in Radiology with the Certification of Added Qualification (CAQ) in Interventional Radiology (ABR) (1995, 2005). Trocar Cholecystostomy. HHS Vulnerability Disclosure, Help Do not report removal of the tube prior to replacement. Disclaimer. Disclaimer. In addition, CPT code 47562, which had previously been reviewed in 1995 and 2005, was used as a stable reference service when valuing CPT code 47563. A National Institutes of Health (NIH) consensus statement in 1992 stated that laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones and has become the treatment of choice for many patients. 47538 describes the placement of a completely internal stent (metallic or plastic) via an existing access (prior external biliary catheter or internal/external biliary catheter access) and includes exchange of an existing externally draining biliary catheter (if done); down-conversion to an external catheter (when the original catheter is an internal/external catheter); or removal of a catheter at the end of the procedure. 2 weeks later a cholecystostomy tube check was performed showed persistent cystic duct obstruction. The balloon was inflated within the gallbladder to secure it in place. Messages 77 Best answers 0. Nov 5, 2009. 0000267575 00000 n 0000263284 00000 n 0000158048 00000 n 47490 is an interventional radiology procedure that is less invasive than a laparoscopic procedure - the catheter in the percutaneous procedure would be threaded over a guidewire that was placed with imaging guidance and there would be no incision. 0000011634 00000 n Submit +47542 once per treatment site, for a maximum of two sites treated per session. 0000262431 00000 n Use of modifier 22 is not appropriate if the sole use of the modifier . 0000267204 00000 n 0000214528 00000 n 0000266464 00000 n 0000010623 00000 n The definition for the Drainage root operation provided in the 2013 ICD-10-PCS Reference Manual is "Taking or letting out fluids and/or gases from a body part.". Post-procedure, 16 patients (43.24%) went on to have LC, of which 50% (eight patients) required conversion to open surgery and 25% (four . The procedure of gall bladder removal and Cholecystostomy removal can be performed side by side with the help of laparoscope computer imaging. Answer: If the tube is placed in a new site, submit CPT code 66180 Aqueous shunt to extraocular equatorial plate . 0000266359 00000 n The CPT code for removal of a gastrostomy tube is 43999. Aug 4, 2010 #2 Its 47490 and 75989 Thanks, Abdul Saleem CPC . Surg Endosc. No tubes are left in place at the end of the procedure (add 47537 for tube removal, delete 47531 as bundled with tube removal). Control of postoperative pain, nausea, and vomiting are important to successful same day discharge, and admission rates despite planned same day discharge are reported to be 1-39%; patients older than age 50 may be at increased risk for admission (Kasem, et al. 1991 Mar;78(3):153-7 0000005679 00000 n 0000007656 00000 n Epub 2006 Feb 27. Is it because the word external in 47533? 0000305890 00000 n Here we present 2 cases with severe acute cholecystitis that required placement of laparoscopic cholecystostomy (LC) tube. At the time of surgery, three of the 100 patients had gallbladders judged too severely inflamed for laparoscopic cholecystectomy. We are looking for thought leaders to contribute content to AAPCs Knowledge Center. Postcholecystectomy syndrome. Epub 2020 Nov 20. When done via an existing access, submit a code describing a catheter exchange, removal, or conversion (e.g., 47535-47537). 0000267101 00000 n J Laparoendosc Adv Surg Tech A. Does anyone have info on the code to use for this? 2016 Mar;30(3):1028-33. doi: 10.1007/s00464-015-4290-y. Inpatient procedure costs include the hospital payment for the entire stay associated with the surgery. A search of the hospital's radiology information service was performed using the keywords "percutaneous cholecystostomy," "gallbladder drain," and "cholecystostomy tube" and the relevant Current Procedural Terminology codes. 0000292586 00000 n PostOperative Diagnosis: Acute and chronic cholecystitis with cholelithiasis. 0000047416 00000 n Cholangiography is bundled with the new external biliary catheter, internal/external catheter, and biliary stent placement codes. Just as catheter drainage of acute infection with interval appendectomy is accepted in patients with periappendiceal abscess, tube cholecystostomy with interval laparoscopic cholecystectomy has a role in the management of select patients with acute cholecystitis.6 These patients can be then sent home on a course of antibiotics to help them recover from the acute illness. We find that this approach has several advantages, including mobilization of the cecum to allow the tube to be placed below the waistline for optimal cosmesis and comfort, increased safety provided by direct vision of needle access to the cecum, and increased security of the cecum to the abdominal wall allowing for safer tube replacement should it become dislodged in the early postoperative period. Conversion to open surgery may be necessary in cases where the anatomy is unclear or complications are encountered. 0000280217 00000 n 0000004643 00000 n Enter the email address you signed up with and we'll email you a reset link. Percutaneous cholecystostomy, which includes placement of a drainage catheter into the gallbladder (47490 Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation), remains unchanged in 2016. 0000058109 00000 n 0000266569 00000 n registered for member area and forum access. 0000214222 00000 n Next month, well cover CPT updates for percutaneous neurologic intervention. You certainly do not want to code diagnostic laparoscopy and call the drain placement inclusive because you'll short change the doctor. Routine change of cholecystostomy tube. Eren Berber, Kristen L Engle, Andreas String, et.al. 0000284942 00000 n Physicians are advised to use the CPT code that accurately describes the basic surgical procedure. Percutaneous transhepatic gallbladder drainage (PTGBD) is indicated for patients with acute cholecystitis (AC) who are not indicated for urgent surgery, but external tubes reduce quality of life (QOL) while waiting for elective surgery. 527 0 obj <> endobj Submit +47543 only once per date of service. Now that the infection has subsided, a diagnostic cholangiogram is performed, showing distal common bile stenosis. They therefore underwent laparoscopic placement of a cholecystostomy tube. 0000264294 00000 n 0000310963 00000 n New Codes for 2016 There are 14 new biliary intervention codes for 2016 (see New Biliary Intervention Codes for 2016). The five procedures are laparoscopic cholecystectomy (CPT procedure code 47562 for outpatient surgeries and ICD-9 procedure code 5123 for inpatient surgeries), laparoscopic appendectomy (CPT 44970 and ICD-9 procedure code 4701), arthrodesis (CPT 22845 and 22551; and ICD-9 procedure code 8102), laparoscopic total hysterectomy (CPT 58570, 58571, 58572, and 58573; and ICD-9 procedure code 6841), and laparoscopic vaginal hysterectomy (CPT 58552, 58553, and 58554; and ICD-9 procedure code 6841). 0000211822 00000 n For a better experience, please enable JavaScript in your browser before proceeding. What is documented here is not a percutaneous procedure. He was on the AAPC National Advisory Board from 2005-2009, and is a member of the Nashville, Tenn., local chapter. Surg Endosc. Laparoscopic cholecystectomy can be quite challenging in especially in certain situations. 0000264507 00000 n As CPT Assistantnotes, however, that for some patients: replacing a G-tube is more complicated, such as when a gastrostomy tract has not matured or when the G-tube has been out for many hours or in cases where cooperation of the patient is difficult, as in some children or confused patients. +CPT Code 47550 is an Add-On code and must be reported with a primary procedure. Surg Clin North Am. 0000283275 00000 n %PDF-1.4 % 47525 is for change of biliary tube and on the lay description in our coding companion it states this is for a tube in the liver. Cpt Code For Laparoscopic Cholecystectomy - Peekapoo - S. The CPT code for this is 47564. [/QUOTE] code 47490.. In addition, CPT code 47562, which had previously been reviewed in 1995 and 2005, was used as a stable reference service when valuing CPT code 47563. 0000265781 00000 n Surgery was recommended. Last edited: Aug 4, 2010. For the Cy2013 PFS, these codes are correctly ranked. 0000264401 00000 n 0000012348 00000 n The following codes involve placement of an external or internal/external biliary drainage catheter: trailer Note that both 43762 and 43763 describe G-tube replacement without any type of guidance. Cholecystostomy is the procedure of putting a tube in gall bladder. xref A Jackson Pratt (JP) drain was inserted adjacent to it in the gallbladder fossa. 0000290962 00000 n An imaging code (47531 or 47532) can be submitted instead if the above catheter codes are not performed. Curr Urol Rep. 2019 Jun 10;20(8):41. doi: 10.1007/s11934-019-0909-1. #1. 0000265253 00000 n About 6 weeks later, the patient underwent laparoscopic cholecystectomy, with removal of cholecystostomy tube- uneventfully. H\_k@w?soH~ ThTy9\~?>utxnlYTCu}wtt:wic|c;?aMnkSWyI{}}CU1+X-,vueS^YY"RyB2ow;W=gzK%r\ {f,L+"!ayy 0000268127 00000 n 0000206666 00000 n 0000010421 00000 n 0000207938 00000 n Eradi B, Hamrick M, Bischoff A, Frischer JS, Helmrath M, Hall J, Pea A, Levitt MA. Patient was taken for attempted laparoscopic cholecystectomy. Question: You recommend code 47536 for cholecystostomy tube change in the IR reference instead of 47490-52. The balloon was then inflated within the gallbladder to secure it in place (Figure 2).
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