Documentation Articles and Resources

News and Important Information

Documentation is essential to establishing medical necessity compliance and the level of services provided to the patient. Treatment plans and Outcomes Assessment Tools (OATs) are crucial required elements required for appropriate documentation, this page offers Tools and important resources to help with documentation compliance.

CMS Complying With Medical Record Documentation Requirements Jan 2023

Webinar | Major Changes to E/M Coding and Documentation 

CGS - Documentation Checklists for DME Supplies Updated: 02.08.24
HCA Healthcare - POLICY: Coding Documentation for Outpatient Services

Where to find Documentation TIPS in Find-A-Code: 

Learning Corner

Medical Coding with BLEU: Understanding Medical Record Documentation Language for Medical Coders

MLN Fact Sheet: Complying With Medical Record Documentation Requirements

AHIMA: Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories



 
 
 
 
 

Resources

Select the title to see a summary and a link to the full article.  some articles require a subscription to view.

Accurately Reporting Signs and Symptoms with ICD-10-CM Codes

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.

Documenting and Reporting Postoperative Visits

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period? 

Answers to Evaluation & Management Questions From Webinar Attendees

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Following every Evaluation & Management (E/M) webinar, we receive questions from attendees reflecting the specific circumstances they have identified within their individual organizations. We wanted to take some time to address some individual questions for the benefit of others who have some of the same questions. These questions are related to scoring Medical Decision Making (MDM) in the E/M coding guidelines.

Reporting Drug Wastage with Modifier JW and NEW Modifier JZ

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Modifier JW has been around since 2003 with changes in Medicare policies to ensure standard utilization in 2017; however, because of a continued lack of reporting consistency, Medicare has created and implemented policy related to reporting a new modifier, JZ. How does this impact Medicare reimbursement and why is this modifier so important?

Finding Patterns of Complexity in the Medical Decision Making (MDM) Table

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Changes to the Medical Decision Making (MDM) Table in 2023 reflect the work performed in the facility setting in addition to the work involved in Evaluation and Management (E/M) scoring in other places of service. Taking the time to really look closely at the MDM Table and identify patterns in wording and scoring helps coders to understand scoring in an easier way.

E/M Scoring Questions

by  Wyn Staheli, Director of Content - innoviHealth

Evaluation and Management visits are often the “bread and butter” of an organization. Thus, correctly scoring encounters is essential to ensuring proper reimbursement. The element of “Risk” is only one of the three elements of Medical Decision Making (MDM), but understanding what is meant by all the definitions within each element is critical.

Seven Reasons to Standardize Medical Records

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

The standardization of medical records offers numerous benefits for healthcare systems, providers, and patients. By ensuring interoperability, improved workflows, better patient safety, supporting research endeavors, and optimizing resource allocation, standardized records contribute to improved efficiency, quality of care and especially patient outcomes. Here are seven reasons to standardize medical records.

Advancements in Coding Hospital Observation Care Services in 2023

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Hospitals are increasingly adopting innovative solutions to improve patient care and optimize processes and many of these solutions follow immediately the recent CPT and Medicare coding changes.  In 2023 coding of hospital observation care services underwent significant changes enabling healthcare providers to accurately document and bill for the sick or injured patient that requires a higher level of medical services between the emergency room care and hospital admission. This article explores the key changes in coding hospital observation care services and their impact on healthcare delivery.

Computer-Assisted Medical Coding (CAC) vs Autonomous Medical Coding to Strike the Perfect Balance Between Automation and Human Coder Expertise

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Healthcare is witnessing a digital revolution of sorts with advancements in technology that seem to transform many aspects of patient care. An example of this transformation involves the evolution of medical coding, where computer-assisted medical coding (CAC) and the use of artificial intelligence (AI) in medical coding are revolutionizing the way healthcare organizations document, process, and ensure medical necessity for healthcare services.

Identifying the Components of a High-Risk Evaluation and Management Service

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

How comfortable are you with selecting a high-level Evaluation and Management service and how often do you see high-risk E/M codes reported? In 2023, the CPT coding guidelines for E/M coding changed drastically, moving from a 3-key component scoring system to determining the final code using either time or medical decision making (MDM), but accurately scoring and having confidence in the selection of a high-level E/M service remains challenging.

Understanding, Identifying, and Reporting Combination Codes

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Coders often see conditions that seem to always be reported together. Diabetic patients tend to develop other conditions as the diabetes continues to progress instead of improving. Combination codes are one of those types of codes that identify multiple conditions or diseases but have their own set of special coding guidelines.

Hernia Repair Coding in 2023

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Hernia repair coding underwent significant changes in 2023, with the deletion of more than a dozen open and laparoscopic hernia repair codes. This revision was linked to an AMA RUC review of codes that had a "site-of-service" anomaly where the global period was based on E/M service codes they had previously calculated as performed inpatient instead of outpatient. As a result, big changes took place this year in hernia-repair coding.

Identifying the Admitting, Principal, Primary, and Secondary Diagnoses

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

If you have ever had a difficult time differentiating between the admitting diagnosis, principal diagnosis, and primary diagnosis then look no further. Each of these diagnoses play an important role in reporting services and ensuring correct coding and sequencing has occurred. Let's take a closer look at each of these diagnosis types and when they are reported.

Five Documentation Habits Providers Can Use/Implement to Improve Evaluation & Management (E/M) Scoring

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Provider education on E/M coding updates is vital to the success of any organization, but how do you whittle down the massive information into bite-sized pieces the providers can learn in just a few minutes? Check out the five steps we have identified to teach providers in just a few minutes that can significantly impact and improve coding outcomes.

Focusing on the Diagnosis Instead of the Problems Addressed Can Impact E/M Scores

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Many diagnosis code descriptions contain language such as severity or complexity, acute on chronic, and others that may mislead a coder into thinking they are coding a condition that is more severe than it really is. How can we be certain we are scoring the patient's problems instead of their diagnoses?

7 Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth Fraud

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

A recent review of telehealth services reported in Medicare claims data during the pandemic where these seven measures for identifying suspected fraud, waste, and abuse were applied, revealed more than a thousand Medicare providers potentially committed fraud during this period. What are the measures the OIG applied during their review, and how will that impact future telehealth guidelines moving forward?

GERD: Improving the Coding, Documentation, Billing, and Reimbursement Flow

by  Jessica Hocker, CPC, CPB, CRC

GERD is a common condition where stomach acid flows back into the esophagus, causing symptoms like heartburn. It is treated with lifestyle changes, medication and surgery. Proper documentation is important for accurate coding and treatment. Providers should stay up-to-date with coding and billing policies.

Compliance Billing: Power Mobility Devices

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

In May of 2022, the OIG conducted a nationwide audit of Power Mobility Device (PMD) repairs for Medicare beneficiaries. The findings were not favorable; the audit revealed CMS paid 20% of durable medical suppliers incorrectly during the audit period of October 01, 2018- September 30, 2019. This was a total of $8 million in device repairs out of $40 million paid by CMS. We gathered information in this article to assist providers and suppliers in keeping the payments received, protecting beneficiaries, and assisting you in ensuring compliance.

Leveraging Hierarchical Condition Category (HCC) Coding to Improve Overall Healthcare

by  Kem Tolliver, CMPE, CPC, CMOM

Diagnosis code usage is a major component of optimizing HCCs to improve overall healthcare. Readers will gain insight into how accurate diagnosis code usage and selection impacts reimbursement and overall healthcare.

Accurately Reporting Diabetic Medication Use in 2023

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Along with the ICD-10-CM coding updates, effective as of October 1st, the guidelines were also updated to provide additional information on reporting diabetic medications in both the general diabetic population and pregnant diabetics. Accurate reporting is vital to ensure not only maximum funding for risk adjusted health plans, but also to ensure medical necessity for the services provided to this patient population.

There are 190 related documentation, coding and billing tips.

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Select the title to see a summary and a link to the full webinar information.  some webinars require a subscription to view.

Modalities Used in Your Chiropractic Office 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Electrical stimulation, ultrasound, and mechanical traction are modalities commonly used in chiropractic offices. And they are commonly documented incorrectly or billed improperly. Learn the right (and wrong) ways to get paid for these kinds of services. Join Dr. Evan Gwilliam, certified coder, and all-around nice guy, as he answers your most burning questions about the CPT codes 97012, 97014/G0283, 97032, and 97035.

A Deep Dive into the 2023 MDM Table 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

2023 brought additional changes to the Medical Decision Making (MDM) table. Even more E/M services are now being scored on either MDM or time. This means that a comprehensive understanding of each of the elements of MDM is critical to ensuring proper code selection. Join us for this informative webinar led by an auditor who regularly reviews these types of claims and knows where the pitfalls are. Learn the differences between definitions and listen to examples of the different levels of each element of MDM.

Auditing EM Services Using the FAC EM Calculator Tool 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Medical decision-making (MDM) is a critical part of code selection for evaluation and management services. It is highly recommended that organizations take time to perform internal audits of billed E/M services to ensure that all required elements are met for the level of MDM reported. Join us for this informative webinar which goes over the different elements of MDM as well as how to use Find-A-Code's Calculator tool to perform your own internal audit.

Formatting & Documentation Best Practices for Evaluation & Management Services 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Join us to learn 7 reasons for standardizing your medical records. We include ways to format the medical record, which can be helpful when documenting the visit. A standard format can provide benefits, such as reminders to record pertinent information, allow for the exchange of PHI between providers, and reduce incomplete or inaccurate data which can lead to inaccurate coding. It can also streamline your workflow, which saves time and money as well as providing more accurate diagnosis and better treatment for patients.

Medical Decision Making | What it is and What it Means to You 

by  Ron Short, DC MCS-P CPC

Presented by Ron Short DC, MCS-P, CPC July 11, 2023 Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 We are hearing a lot about Medical Decision Making (often abbreviated as MDM) now that it is one of the only two ways to determine the appropriate Evaluation and Management code level. In this webinar Dr. Short will show you:  What is Medical Decision Making  When does Medical Decision Making occur  How Medical Decision Making is important to you  How to use Medical Decision Making to your advantage You can obtain the notes for this webinar by subscribing to my e-mail updates at http://www.chiromedicare.net/mailing-list-signup/ (the link to the notes will be in the final welcome e-mail) or by following the link provided in my e-mail update. They will be available by the Monday prior to the webinar presentation.

Documentation Best Practices for Emergency Department Services 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Emergency Department E/M services were significantly revised beginning in 2023. Key components as we knew them are gone and observation services were also changed. Join us for this informative webinar to learn what needs to be done to ensure that your documentation and coding practices are current and compliant.

Looking Closer at High Risk EM Medical Decision Making 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Thursday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 PM EST Join us for a deep dive into the Evaluation & Management element of "Risk". Learn more about the differences between complications, morbidity, and mortality and how that drives coding. What does it really take for an encounter to be considered "High risk?"

PI Medical Necessity verses Healthcare. The difference you make is life changing 

by  Tom Grant DC, Med-Legal Consultant, Pragma Intel Director of Education

The presenting problem as opposed to the causation. Your choice of wording will make a valid compensation claim or kill it. With a career caseload of over 3500 claims, I’ll introduce you to my format of good case write-ups that have won substantial new money for victims and their families and has been kind to me as well.

Setting Goals that Prove Medical Necessity in Your Records 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

'Reduce pain" may be a real goal of chiropractic care, but is it enough? While you may want to help your patients to reduce their pain, goals need to focus on what kinds of functions are affected by that pain. Does it keep the patient from sleeping, from sitting at a desk, from washing their hair when in the shower? Learn how to create goals that are easy to defend and use to justify ongoing treatment in this fun-filled webinar by Dr. Evan Gwilliam, a Certified Professional Medical Auditor.

Medicare’s Rules for Records Requests 

by  Ron Short, DC MCS-P CPC

Medicare continues to request records in order to determine if a claim is payable. However, they have very specific rules and regulations that they are required to follow in requesting the records and reporting the findings. In this webinar Dr. Short will show you: Who can review your records, what needs to be in the request for records, how long you have to respond to a request for records, how to respond to a request for records, how they are required to report the results of the review. You can obtain the notes for this webinar by subscribing to my e-mail updates at http://www.chiromedicare.net/mailing-list-signup/ (the link to the notes will be in the final welcome e-mail) or by following the link provided in my e-mail update. They will be available by the Monday prior to the webinar presentation.

Diagnosis vs Problem EM MDM 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Understanding the differentiation of a "problem" versus a "diagnosis" is essential to proper Evaluation and Management scoring. Join us as we discuss about how these elements play into medical decision-making and what needs to be documented to support E/M complexity.

Keeping up to date on reporting changes... 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Properly reporting split or shared patient encounters can be tricky. The CPT codebook just began defining this type of encounter and the 2023 Medicare Physician Fee Schedule Final Rule included some changes. Tune into this informative webinar to ensure that you are doing things the right way.

Use the Right Modifiers for Chiropractic Billing 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Do you really know when to use the 59 modifier? What about the AT? There are relatively few modifiers to consider when it comes to chiropractic billing and coding, but some payers have their own rules and it can be tricky to know when to use one modifier and not another. In this exciting webinar, Dr. Evan Gwilliam, a certified coder, will clear up all the questions you have about the modifiers you need to consider.

Medical Necessity: it’s far easier to prove than you think, and far more important than you realize. 

by  Tom Grant DC, Med-Legal Consultant, Pragma Intel Director of Education

Besides coding errors, it’s the 2nd most common tool used by health insurers and 3rd party payers to deny care and deny liability. How do you decide what to use as a tool to prove your care is viable and needed? Expensive equipment and elaborate testing procedures are not what you need. It’s as simple to prove as opening a can of beans, unless you don’t have a can opener. I’ll share with you my insider tips and experience as a medical expert on over 3000 successful PI case settlements and give the can opener that you and your patients need you to use to prove medical necessity, and why you’ll need it in treating what I feel is the next great opportunity for Chiropractic: V_______ care.

Current Terminology - 2023 Annual Update Summary

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Be sure you are ready for 2023 with this review of the upcoming coding and reimbursement updates for 2023. This informative webinar discusses changes to CPT codes and guidelines including a summary of the changes to E/M services and an overview of changes to other CPT categories.

Medicare and the ABN for Chiropractic 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Medicare can be intimidating, but fortunately, the rules can be made simple and actually reduce anxiety when applied properly. All you need to know about ABNs and Medicare modifiers will all be covered in this presentation so that you can feel confident you know you are doing things right. 

Dealing with the Little Coding Conundrums 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Coding 2022 Care Management Services 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Do Minor Procedures Feel like Major Work? 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Reporting Telemedicine Services by Aimee Wilcox 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

What do Chiropractors Need to do to Comply with the No Surprises Act? 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Anyone who sees patients who have services that are not covered by insurance needs to know about the No Surprises Act. In this quick webinar, Dr. Gwilliam will show you how to properly notify patients of their options and create a Good Faith Estimate, as required by this law. Expect this…

Medicare Audit, Do-it-yourself 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Don't wait for Medicare to look over your records and try to find deficiencies. Dr. Gwilliam, a Certified Professional Medical Auditor, will show you how to find your own deficiencies, and fix them before they become a compliance or financial concern. This isn't just for Medicare either. If you can…

Chiropractic Documentation: The Subjective Element 

by  Ron Short, DC MCS-P CPC

The Subjective element of S.O.A.P. is where we document what the patient tells us.  But what is the best way to gather this information?  In this webinar Dr. Ron Short will review the guidelines for the subjective element and explain the best way to gather information from the patient.&…

Chiropractic Documentation: The S.O.A.P. Format and Additional Information 

by  Ron Short, DC MCS-P CPC

We have all heard of the S.O.A.P. format for our documentation. But what does each element mean and what additional information do we need in our documentation? In this webinar Dr. Ron Short will review the S.O.A.P. documentation format and discuss what additional information you need document. In…

Chiropractic Manipulative Treatment: Coding and Documentation 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

The most commonly used procedure in chiropractic is the chiropractic adjustment, also known as chiropractic manipulative treatment or CMT. There are nuances to the CPT and ICD-10 codes and Medicare guidelines that must be mastered by any chiropractor hoping to find success when creating their…

Chiropractic Treatment Paradigm 2021 

by  Ron Short, DC MCS-P CPC

Chiropractic care is different from medical care. We know that but how do we explain it. Reviewers deny claims that are medically necessary because they don’t know what they are looking at when they review our claims. Dr. Ron Short will explain how to approach these reviewers in this…

New Dental Codes for 2021 and Find-A-Code Dental Tools/Resources 

by  Christine Taxin, President - Links2Success

Outline of Presentation: - Why Dental coding is changing - New 2021 Dental Codes - Why Cross Coding is Not a Choice - New Dental Tools & Resources in Find-A-Code Be ready for 2021 with complete understanding of the new dental codes. Understand what codes are not covered under dental, and how to bill with medical codes.

Dental Medical Billing & Coding Certification on QPro.com - Your Dental Certification Destination 

by  Christine Taxin, President - Links2Success  and  LaMont J. Leavitt, CEO - innoviHealth

QPro.com is the industry leader for dental coding and billing certifications. The credentialing exams are hosted and administered by QPro.com. To earn dental-to-medical billing credentials, candidates must pass at least three exams including the requisite Qualified Medical Coder/Biller Exam. From there, candidates can earn designations in nine specializations, such as dental implant coding, oral surgery, sleep apnea, sedation dentistry, and coding and reimbursement for CBCT scans.

Strategies for Improving Cash Flow and Collections - Starting Now 

by  Brandy Brimhall, CPC CMCO CPCO CCCPC CPMA QCC

August 18, 2020 Join this webinar for a birds-eye review of crucial components of your practice revenue cycle system. Inefficient or unattended revenue cycle systems result in a tremendous loss of time and money for practices. So often, that additional cash flow that practices are seeking, are…

Rock Solid Care Plans 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Don't ever let anyone challenge your care plans ever again. If you can know what the regulators are looking for while still being free to deliver the care you deem to be best for your patient, then you win. And your patient wins. Join Dr. Gwilliam, certified professional medical auditor, and all around nice guy, as he guides you to the steps to create rock solid care plans that will stand up to third party scrutiny.

Proving Medical Necessity and Functional Improvement 

by  Ron Short, DC MCS-P CPC

Medicare is required by law to pay for care that is medically necessary. Medicare considers functional improvement to be the primary indicator of medical necessity for chiropractic care. It is up to you, the doctor, to prove functional improvement and medical necessity with your documentation. Dr. Short will show you how to use common practice tools to document functional improvement, medical necessity and maximum medical improvement.

Chiropractic Manipulative Treatment (CMT) Coding and Documentation (Part 1) 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

The most used codes in chiropractic are 98940, 98941, 98942, and 98943. In this webinar, Dr. Gwilliam will go over the fundamentals of these codes and make sure you are proficient with them. They probably play a bigger part of your practice than any other code, so it is worth it to make sure you are reporting them correctly. By the end of this presentation you will be able to diagnose, document, and code properly for CMT, as well as avoid common mistakes.

Coding and Auditing Wound Care 

by  Find-A-Code™

In this webinar, Aimee will review wound care coding and auditing information for wound care services, including proper modifier use, NCCI edits, Medicare coverage guidelines, and documentation requirements.

Coding and Auditing TeleHealth Services 

by  Find-A-Code™

Do you report or audit Telemedicine services now or are you considering offering them? Come and learn more about the rules and guidelines surrounding Telehealth services including, documentation requirements, eligible CPT and HCPCS Level II codes, modifiers, and the newest updates to Medicare Telehealth policies.

Coding Auditing Inpatient Evaluation and Management — A Hands-On Experience 

by  Find-A-Code™

Do your providers perform and report Evaluation and Management (E/M) services in the inpatient setting? Does the documentation match with the services being billed, or does it fall short? Join Aimee for a hands-on audit of an inpatient E/M service and get an idea of the information and documentation needed to correctly code inpatient E/M services.

Surgical Coding and Auditing 

by  Find-A-Code™

Ever wonder what an auditor is looking for when they review your surgical coding? Join Aimee and review the basic rules and documentation requirements. We’ll tear apart a couple of operative reports, code them, review NCCI edits, modifiers, and more. Get an idea of how you are doing and things you may want to incorporate into your practice to be better prepared when an audit comes your way. Also, we’ll review our cool Code-A-Note tool and how it can help you locate CPT and ICD-10-CM codes quickly. This tool is great for new coders, coders new to a specialty, difficult coding situations, or anyone who just wants a second opinion on their code options.

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