Coding, Diagnosing, Billing, Coding, Diagnosing, Billing, Reimbursement & Reimbursement &

Documentation Strategies for Documentation Strategies for Neuropsychological Services:Neuropsychological Services:Medicare as the BenchmarkMedicare as the Benchmark

American Psychological AssociationAmerican Psychological AssociationAugust 10, 2003August 10, 2003Toronto, CanadaToronto, Canada

Antonio E. Puente, Ph.D.Antonio E. Puente, Ph.D.

Department of PsychologyDepartment of Psychology

University of North Carolina at University of North Carolina at WilmingtonWilmington

Wilmington, NC 28403Wilmington, NC 28403

BackgroundBackgroundNorth Carolina Psychological North Carolina Psychological

AssociationAssociationAmerican Medical Association’s Current American Medical Association’s Current

Procedural Terminology Committee Procedural Terminology Committee (IV/V)(IV/V)

Health Care Finance Administration’ Health Care Finance Administration’ Working Group for a Model Mental Working Group for a Model Mental Health policyHealth policy

Center for Medicare/Medicaid Services’ Center for Medicare/Medicaid Services’ Medicare Coverage Advisory CommitteeMedicare Coverage Advisory Committee

Development of NAN’s new PAIODevelopment of NAN’s new PAIOConsultant with the State Medicaid Consultant with the State Medicaid

Office; Blue Cross/Blue ShieldOffice; Blue Cross/Blue ShieldAPA; Council of Rep, Division 40, P & PAPA; Council of Rep, Division 40, P & P

Purpose of PresentationPurpose of Presentation

• To explain the role of the Medicare To explain the role of the Medicare program in benchmarking all forms program in benchmarking all forms of clinical activities, ranging from the of clinical activities, ranging from the actual provision of services to the actual provision of services to the reimbursement of such servicesreimbursement of such services

Outline of PresentationOutline of Presentation

• MedicareMedicare

• Current Procedural Terminology: Basic Current Procedural Terminology: Basic

• Current Procedural Terminology: Current Procedural Terminology: RelatedRelated

• Relative Value UnitsRelative Value Units

• Current Problems & Possible SolutionsCurrent Problems & Possible Solutions

Medicare: OverviewMedicare: Overview

• Why MedicareWhy Medicare

• Medicare ProgramMedicare Program

• Local Medical ReviewLocal Medical Review

Medicare: WhyMedicare: Why

• TheThe Standard Standard – CodingCoding– ValueValue– DocumentationDocumentation

• Approximately two thirds of InstitutionsApproximately two thirds of Institutions

• Approximately half of Outpatient OfficesApproximately half of Outpatient Offices

• Becoming the Standard for Workers Comp.Becoming the Standard for Workers Comp.

• Increasing Percentage for Forensic WorkIncreasing Percentage for Forensic Work

Medicare: OverviewMedicare: Overview

• New Name: HCFA now CMSNew Name: HCFA now CMS– Centers for Medicare and Medicaid ServicesCenters for Medicare and Medicaid Services

• New Charge: SimplifyNew Charge: Simplify

• New Organization: Beneficiary, Medicare, New Organization: Beneficiary, Medicare, MedicaidMedicaid

• BenefitsBenefits– Part A (Hospital)Part A (Hospital)– Part B (Supplementary)Part B (Supplementary)– Part C (Medicare+ Choice)Part C (Medicare+ Choice)

Medicare: Local ReviewMedicare: Local Review

• Local Medical Review PolicyLocal Medical Review Policy

• Carrier Medical DirectorCarrier Medical Director

• Policy PanelsPolicy Panels

Current Procedural Current Procedural Terminology: OverviewTerminology: Overview• BackgroundBackground• Codes & CodingCodes & Coding• Existing CodesExisting Codes• New Codes (effective 01.01.02; revised New Codes (effective 01.01.02; revised

03.15.02)03.15.02)• Model System X Type of ProblemModel System X Type of Problem• Medical NecessityMedical Necessity• DocumentingDocumenting• TimeTime

CPT: BackgroundCPT: Background

• American Medical AssociationAmerican Medical Association– Developed by Surgeons (& Physicians) in 1966 Developed by Surgeons (& Physicians) in 1966

for Billing Purposesfor Billing Purposes– 7,500 Discrete Codes7,500 Discrete Codes

• HCFA/CMSHCFA/CMS– AMA Under License with CMSAMA Under License with CMS– CMS Now Provides Active Input into CPTCMS Now Provides Active Input into CPT

• CongressCongress– Trent Lott (2001)Trent Lott (2001)

CPT: Background/DirectionCPT: Background/Direction

• Current System = CPT 5Current System = CPT 5

• CategoriesCategories– I= Standard Coding for Professional I= Standard Coding for Professional

ServicesServices– II = Performance MeasurementII = Performance Measurement– III = Emerging TechnologyIII = Emerging Technology

CPT: Applicable CodesCPT: Applicable Codes

• Total Possible Codes = 7,500Total Possible Codes = 7,500

• Possible Codes for Psychology = Possible Codes for Psychology = Approximately 40 to 60Approximately 40 to 60

• Sections = Five Separate SectionsSections = Five Separate Sections– PsychiatryPsychiatry– BiofeedbackBiofeedback– Central Nervous AssessmentCentral Nervous Assessment– Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation– Health & Behavior Assessment & ManagementHealth & Behavior Assessment & Management

CPT: Development of a CPT: Development of a CodeCode

• InitialInitial– HCPAC HCPAC

• PrimaryPrimary– CPT Work GroupCPT Work Group– CPT PanelCPT Panel

• Time FrameTime Frame– 3-5 years3-5 years

CPT: PsychiatryCPT: Psychiatry

• SectionsSections– Interview vs. InterventionInterview vs. Intervention– Office vs. InpatientOffice vs. Inpatient– Regular vs. Evaluation & ManagementRegular vs. Evaluation & Management– OtherOther

• Types of InterventionsTypes of Interventions– Insight, Behavior Modifying, and/or Insight, Behavior Modifying, and/or

Supportive vs. InteractiveSupportive vs. Interactive

CPT: Psychiatry (cont.)CPT: Psychiatry (cont.)

• Time ValueTime Value– 30, 60, or 9030, 60, or 90

• InterviewInterview– 9080190801

• InterventionIntervention– 90804 - 9085790804 - 90857

CPT: BiofeedbackCPT: Biofeedback

• Psychophysiological TrainingPsychophysiological Training– 9090190901

• BiofeedbackBiofeedback– 9087590875

CPT: CNS AssessmentCPT: CNS Assessment

• InterviewInterview– 9611596115

• TestingTesting– Psychological = 96100; 96110/11Psychological = 96100; 96110/11– Neuropsychological = 96117Neuropsychological = 96117– Other = 96105, 96110/111Other = 96105, 96110/111

CPT: 96117 in DetailCPT: 96117 in Detail

• Number of Encounters in 2000 = Number of Encounters in 2000 = 293,000293,000

• Number of Medical Specialties Using Number of Medical Specialties Using 96117 = over 4096117 = over 40

• Psychiatry & Neurology = Psychiatry & Neurology = Approximately 3% eachApproximately 3% each

• Clinics or Other Groups = 3%Clinics or Other Groups = 3%

• Unknown Data = Use of TechniciansUnknown Data = Use of Technicians

CPT: Physical Medicine & CPT: Physical Medicine & RehabilitationRehabilitation

• 97770 now 9753297770 now 97532

• Note: 15 minute incrementsNote: 15 minute increments

CPT: Health & Behavior CPT: Health & Behavior Assessment & Mngmt.Assessment & Mngmt.

• Purpose: Medical DiagnosisPurpose: Medical Diagnosis

• Time: 15 Minute IncrementsTime: 15 Minute Increments

• AssessmentAssessment

• InterventionIntervention

Rationale: GeneralRationale: General• Acute or chronic (health) illness may not Acute or chronic (health) illness may not

meet the criteria for a psychiatric diagnosismeet the criteria for a psychiatric diagnosis

• Avoids inappropriate labeling of a patient as Avoids inappropriate labeling of a patient as having a mental health disorderhaving a mental health disorder

• Increases the accuracy of correct coding of Increases the accuracy of correct coding of professional servicesprofessional services

• May expand the type of assessments and May expand the type of assessments and interventions afforded to individuals with interventions afforded to individuals with health problemshealth problems

Rationale: Specific Rationale: Specific ExamplesExamples

• Patient Adherence to Medical Patient Adherence to Medical TreatmentTreatment

• Symptom Management & ExpressionSymptom Management & Expression

• Health-promoting BehaviorsHealth-promoting Behaviors

• Health-related Risk-taking BehaviorsHealth-related Risk-taking Behaviors

• Overall Adjustment to Medical IllnessOverall Adjustment to Medical Illness

Overview of CodesOverview of Codes

• New SubsectionNew Subsection

• Six New CodesSix New Codes– AssessmentAssessment– InterventionIntervention

• Established Medical Illness or Established Medical Illness or DiagnosisDiagnosis

• Focus on Biopsychosocial FactorsFocus on Biopsychosocial Factors

Assessment ExplanationAssessment Explanation

• Identification of psychological, Identification of psychological, behavioral, emotional, cognitive, and behavioral, emotional, cognitive, and social factorssocial factors

• In the prevention, treatment, and/or In the prevention, treatment, and/or management of management of physical healthphysical health problemsproblems

• Focus on biopsychosocial factors (not Focus on biopsychosocial factors (not mental health)mental health)

Assessment (continued)Assessment (continued)

• May include (examples);May include (examples);– health-focused clinical interviewhealth-focused clinical interview– behavioral observationsbehavioral observations– psychophysiological monitoringpsychophysiological monitoring– health-oriented questionnaireshealth-oriented questionnaires– and, assessment/interpretation of the and, assessment/interpretation of the

aforementioned aforementioned

Intervention ExplanationIntervention Explanation

• Modification of psychological, Modification of psychological, behavioral, emotional, cognitive, and/or behavioral, emotional, cognitive, and/or social factors social factors

• Affecting physiological functioning, Affecting physiological functioning, disease status, health, and/or well beingdisease status, health, and/or well being

• Focus = improvement of health with Focus = improvement of health with cognitive, behavioral, social, and/or cognitive, behavioral, social, and/or psychophysiological procedurespsychophysiological procedures

Intervention (continued)Intervention (continued)

• May include the following procedures May include the following procedures (examples);(examples);– CognitiveCognitive– BehavioralBehavioral– SocialSocial– Psychophysiological Psychophysiological

Diagnosis MatchDiagnosis Match

• Associated with acute or chronic Associated with acute or chronic illnessillness

• Prevention of a physical illness or Prevention of a physical illness or disabilitydisability

• Not meeting criteria for a psychiatric Not meeting criteria for a psychiatric diagnosis or representing a diagnosis or representing a preventative medicine servicepreventative medicine service

Health & Behavior Health & Behavior Assessment CodesAssessment Codes

• 9615096150– Health and behavior assessment (e.g., Health and behavior assessment (e.g.,

health-focused clinical interview, health-focused clinical interview, behavioral observations, behavioral observations, psychophysiological monitoring, health-psychophysiological monitoring, health-oriented questionnaires)oriented questionnaires)

– each 15 minuteseach 15 minutes– face-to-face with the patientface-to-face with the patient– initial assessmentinitial assessment

• 9615196151– re-assessmentre-assessment

Health & Behavior Health & Behavior Intervention CodesIntervention Codes• 9615296152

– Health and behavior interventionHealth and behavior intervention– each 15 minuteseach 15 minutes– face-to-faceface-to-face– individualindividual

• 9615396153– group (2 or more patients)group (2 or more patients)

• 9615496154– family (with the patient present)family (with the patient present)

• 9615596155– family (without the patient present)family (without the patient present)

Relative Values for Health & Relative Values for Health & Behavior A/I CodesBehavior A/I Codes

• 96150 = .5096150 = .50

• 96151 = .4896151 = .48

• 96152 = . 4696152 = . 46

• 96153 = .1096153 = .10

• 96154 = .4596154 = .45

• 96155 = .4496155 = .44

CPT: Model SystemCPT: Model System

• PsychiatricPsychiatric

• NeurologicalNeurological

• Non-Neurological MedicalNon-Neurological Medical

CPT: Psychiatric ModelCPT: Psychiatric Model(Children & Adult)(Children & Adult)• InterviewInterview

– 9080190801

• TestingTesting– 96100, or96100, or– 96110/1196110/11

• InterventionIntervention– e.g., 90806e.g., 90806– The challenge of New MexicoThe challenge of New Mexico

CPT: Neurological ModelCPT: Neurological Model(Children & Adult)(Children & Adult)

• InterviewInterview– 9611596115

• TestingTesting– 9611796117

• InterventionIntervention– 9753297532

CPT: Non-Neurological CPT: Non-Neurological Medical ModelMedical Model(Children & Adult)(Children & Adult)

• Interview & AssessmentInterview & Assessment– 96150 (initial)96150 (initial)– 96151 (re-evaluation)96151 (re-evaluation)

• InterventionIntervention– 96152 (individual)96152 (individual)– 96153 (group)96153 (group)– 96154 (family with patient)96154 (family with patient)– 96155 (family without patient)96155 (family without patient)

CPT: New ParadigmsCPT: New Paradigms

• Evaluation & ManagementEvaluation & Management

CPT: Evaluation & CPT: Evaluation & ManagementManagement

• Role of Evaluation & Management Role of Evaluation & Management CodesCodes– ProceduresProcedures– Case ManagementCase Management

• Limitations Imposed by AMA’s House Limitations Imposed by AMA’s House of Delegatesof Delegates

• Health & Behavior Codes as an Health & Behavior Codes as an Alternative to E & M CodesAlternative to E & M Codes

CPT: DiagnosingCPT: Diagnosing

• PsychiatricPsychiatric– DSMDSM

•The problem with DSM and neuropsych The problem with DSM and neuropsych testing of developmentally-related testing of developmentally-related neurological problemsneurological problems

• Neurological & Non-Neurological Neurological & Non-Neurological MedicalMedical– ICDICD

CPT: Medical NecessityCPT: Medical Necessity

• Scientific & Clinical NecessityScientific & Clinical Necessity

• Local Medical Review or Carrier Local Medical Review or Carrier Definition of NecessityDefinition of Necessity

• Necessity = CPT x DXNecessity = CPT x DX

• Necessity Dictates Type and Level of Necessity Dictates Type and Level of ServiceService

• Necessity Can Only be Proven with Necessity Can Only be Proven with DocumentationDocumentation

CPT: DocumentingCPT: Documenting

• PurposePurpose

• Payer RequirementsPayer Requirements

• General PrinciplesGeneral Principles

• HistoryHistory

• ExaminationExamination

• Decision MakingDecision Making

Documentation: PurposeDocumentation: Purpose

• Medical NecessityMedical Necessity

• Evaluate and Plan for TreatmentEvaluate and Plan for Treatment

• Communication and Continuity of Communication and Continuity of CareCare

• Claims Review and PaymentClaims Review and Payment

• Research and EducationResearch and Education

Documentation: Payer Documentation: Payer RequirementsRequirements

• Site of ServiceSite of Service

• Medical Necessity for Service Medical Necessity for Service ProvidedProvided

• Appropriate Reporting of ActivityAppropriate Reporting of Activity

Documentation: General Documentation: General PrinciplesPrinciples• Rationale for ServiceRationale for Service

• Complete and LegibleComplete and Legible

• Reason/Rationale for ServiceReason/Rationale for Service

• Assessment, Progress, Impression, or Assessment, Progress, Impression, or DiagnosisDiagnosis

• Plan for CarePlan for Care

• Date and Identity of ObserveDate and Identity of Observe

• TimelyTimely

• ConfidentialConfidential

Documentation: Basic Documentation: Basic Information Across All CodesInformation Across All Codes• DateDate• Time, if applicableTime, if applicable• Identify of ObserverIdentify of Observer• Reason for ServiceReason for Service• StatusStatus• ProcedureProcedure• Results/FindingResults/Finding• Impression/DiagnosesImpression/Diagnoses• DispositionDisposition• Stand AloneStand Alone

Documentation:Documentation:Mental StatusMental Status• LanguageLanguage

• Thought ProcessesThought Processes

• InsightInsight

• JudgmentJudgment

• ReliabilityReliability

• ReasoningReasoning

• PerceptionsPerceptions

• SuicidalitySuicidality

• ViolenceViolence

• Mood & AffectMood & Affect

• OrientationOrientation

• MemoryMemory

• AttentionAttention

• IntelligenceIntelligence

Documentation:Documentation:Neurobehavioral Status Neurobehavioral Status ExamExam• AttentionAttention

• MemoryMemory

• Visuo-spatialVisuo-spatial

• Language Language

• PlanningPlanning

Documentation: TestingDocumentation: Testing

• Names of TestsNames of Tests

• Interpretation of TestsInterpretation of Tests

• DispositionDisposition

• Time/DatesTime/Dates

Documentation: Documentation: InterventionIntervention

• Reason for ServiceReason for Service

• StatusStatus

• InterventionIntervention

• ResultsResults

• ImpressionImpression

• DispositionDisposition

• TimeTime

Documentation: Ethical Documentation: Ethical IssuesIssues

• How Much and To Whom Should How Much and To Whom Should Information be DivulgedInformation be Divulged

• Medical Necessity vs. ConfidentialityMedical Necessity vs. Confidentiality

TimeTime

• DefiningDefining– Professional (not patient) Time Including:Professional (not patient) Time Including:

•pre, intra & post-clinical service activitiespre, intra & post-clinical service activities

• Interview & Assessment CodesInterview & Assessment Codes– Generally use hourly incrementsGenerally use hourly increments– For new codes, use 15 minute For new codes, use 15 minute

incrementsincrements

• Intervention CodesIntervention Codes– Use 15, 30, or 60 minute incrementsUse 15, 30, or 60 minute increments

Time: TestingTime: Testing

• Quantifying TimeQuantifying Time– Round up or down to nearest incrementRound up or down to nearest increment– Testing = 15 or 60 (probably soon 30)Testing = 15 or 60 (probably soon 30)

• Time Does Not IncludeTime Does Not Include– Patient completing tests, forms, etc.Patient completing tests, forms, etc.– Waiting time by patientWaiting time by patient– Typing of reportsTyping of reports– Non-Professional (e.g., clerical) timeNon-Professional (e.g., clerical) time– Literature searches, new techniques, etc.Literature searches, new techniques, etc.

Time (continued)Time (continued)

• Preparing to See PatientPreparing to See Patient• Reviewing of RecordsReviewing of Records• Interviewing Patient, Family, and OthersInterviewing Patient, Family, and Others• When Doing AssessmentsWhen Doing Assessments::

– Selection of testsSelection of tests– Scoring of testsScoring of tests– Reviewing resultsReviewing results– Interpretation of resultsInterpretation of results– Preparation and report writingPreparation and report writing

Time: Example of 96117Time: Example of 96117

• Pre-ServicePre-Service– Review of medical recordsReview of medical records– Planning of testingPlanning of testing

• Intra-ServiceIntra-Service– AdministrationAdministration

• Post-ServicePost-Service– Scoring, interpretation, integration with Scoring, interpretation, integration with

other records, written report, follow-up...other records, written report, follow-up...

Reimbursement HistoryReimbursement History

• Cost Plus Cost Plus

• Prospective Payment System (PPS)Prospective Payment System (PPS)

• Diagnostic Related Groups (DRGs)Diagnostic Related Groups (DRGs)

• Customary, prevailing & Reasonable Customary, prevailing & Reasonable (CPR)(CPR)

• Resource Based Relative Value System Resource Based Relative Value System (RBRVS)(RBRVS)

• Prospective Payment SystemProspective Payment System

Relative Value Units: Relative Value Units: OverviewOverview

• ComponentsComponents

• UnitsUnits

• ValuesValues

• Current ProblemsCurrent Problems

RVU: ComponentsRVU: Components

• Physician Work Resource ValuePhysician Work Resource Value

• Practice Expense Resource ValuePractice Expense Resource Value

• MalpracticeMalpractice

• GeographicGeographic

• Conversion Factor (approx. $34)Conversion Factor (approx. $34)

RVU: ValuesRVU: Values

• Psychotherapy:Psychotherapy:– Prior Value =1.86Prior Value =1.86– New Value = 2.0+ (01.01.02)New Value = 2.0+ (01.01.02)

• Psych/NP Testing: Psych/NP Testing: – Work value= 0Work value= 0– Hsiao study recommendation = 2.2Hsiao study recommendation = 2.2– New Value = undeterminedNew Value = undetermined

• Health & BehaviorHealth & Behavior– .25 (per 15 minutes increments).25 (per 15 minutes increments)

RVU: AcceptanceRVU: Acceptance

• MedicareMedicare

• Blue Cross/Blue Shield 87%Blue Cross/Blue Shield 87%

• Managed Care 69%Managed Care 69%

• Medicaid 55%Medicaid 55%

• Other 44%Other 44%

• New Trends: Compensation FormulasNew Trends: Compensation Formulas

Current Problems Current Problems • Definition of PhysicianDefinition of Physician• Incident toIncident to• SupervisionSupervision• Face-to-FaceFace-to-Face• TimeTime• RVUsRVUs• Work ValuesWork Values• Qualification of TechniciansQualification of Technicians• Practice ExpensePractice Expense• PaymentPayment• Prospective Payment SystemProspective Payment System• FocusFocus for Fraud & Abuse for Fraud & Abuse

Defining FraudDefining Fraud

• FraudFraud– IntentionalIntentional– PatternPattern

• ErrorError– ClericalClerical– DatesDates

Problem: Fraud & Abuse Problem: Fraud & Abuse • 26 Different Kinds of Fraud Types26 Different Kinds of Fraud Types

• Mental Health ProfiledMental Health Profiled

• Estimates of Less Than 10% Estimates of Less Than 10% RecoveredRecovered

• Psychotherapy Estimates/Day = 9.67 Psychotherapy Estimates/Day = 9.67 hourshours

• Problems with Methodology;Problems with Methodology;– MS level and RNMS level and RN– Limited SamplingLimited Sampling

Problem: FraudProblem: FraudOffice of Inspector Office of Inspector GeneralGeneral• Primary ProblemsPrimary Problems

– Medical Necessity (approximately $5 Medical Necessity (approximately $5 billion)billion)

– DocumentationDocumentation

• PsychotherapyPsychotherapy– IndividualIndividual– GroupGroup

• Psychological TestingPsychological Testing– # of Hours# of Hours– DocumentationDocumentation

Problem: Fraud (cont.)Problem: Fraud (cont.)

• Nursing HomesNursing Homes– Identification Identification – Overuse of ServicesOveruse of Services

• ChildrenChildren• ExperienceExperience

– California; TexasCalifornia; Texas– Corporation AuditCorporation Audit– Company AuditCompany Audit– Personal AuditPersonal Audit

Problem: Fraud (cont.)Problem: Fraud (cont.)

• Estimated Pattern of Fraud AnalysisEstimated Pattern of Fraud Analysis– For-profit Medical CentersFor-profit Medical Centers– For-profit Medical ClinicsFor-profit Medical Clinics– Non-profit Medical CentersNon-profit Medical Centers– Non-profit Medical ClinicsNon-profit Medical Clinics– Nursing HomesNursing Homes– Group PracticesGroup Practices– Individual PracticesIndividual Practices

Current EffortsCurrent Efforts

• ParticipantsParticipants– APA PracticeAPA Practice– Related Organizations (NAN, SPA)Related Organizations (NAN, SPA)

• ActivitiesActivities– E & M Documentation GuidelinesE & M Documentation Guidelines– Medical vs. Mental Health DxMedical vs. Mental Health Dx– SupervisionSupervision

• Three LevelsThree Levels• Physician SupervisionPhysician Supervision

– SurveySurvey• Practice Expense vs. Cognitive WorkPractice Expense vs. Cognitive Work• Professional vs. Technical ComponentProfessional vs. Technical Component

Possible SolutionsPossible Solutions• Better Understanding & Application of CPTBetter Understanding & Application of CPT• More Involvement in BillingMore Involvement in Billing• Comprehensive Understanding of LMRPComprehensive Understanding of LMRP• More Representation/Involvement with More Representation/Involvement with

AMA, CMS,AMA, CMS,& Local Medical Review Panels& Local Medical Review Panels

• Meetings with CMSMeetings with CMS• Survey for Testing CodesSurvey for Testing Codes• APA: Increased Staff & Relationship with APA: Increased Staff & Relationship with

CAPPCAPP• Local Interest GroupsLocal Interest Groups

Possible Solutions: Possible Solutions: ResourcesResources• Web SitesWeb Sites

– cms.orgcms.org

- nanonline.org- nanonline.org– div40.orgdiv40.org– clinicalneuropsychology.usclinicalneuropsychology.us

• PublicationsPublications– Testing Times: Camara, Puente, & Nathan Testing Times: Camara, Puente, & Nathan

(2000)(2000)– General CPT: NAN & Div 40 NewslettersGeneral CPT: NAN & Div 40 Newsletters

Questions? Answers…Questions? Answers…

• Questions?Questions?

• Contact:Contact:– puente@uncw.edupuente@uncw.edu– 910.962.7010910.962.7010