1. Town.maps.USA.com 2015

2. Preoperative

3. Disclosures Ann Lovett Melinda Offer Patty Theurer No Pertinent Disclosures

4. Questions based on National STS Audit Results and your FAQ’s

5. Audience Question Depression (475) The patient has a history of bipolar disease and has been treated with Lithium for many years How do you code Depression? 1. Yes 2. No

6. Correct Answer Depression (475) The patient has a history of bipolar disease and has been treated with Lithium for many years How do you code Depression? 1. Yes 2. No Await Training Manual Update for clarification

7. Audience Question PVD(505) /CVD (525) 65 year old man admitted for CABG. H&P indicates a history of PAD: carotid stenosis, diabetic neuropathy, hypertension, prostate cancer treated with radiation and surgery and a surgical clipping of a cerebral aneurysm. How do you code PVD (505) and CVD (525)? 1.PVD: Yes; CVD: No 2.PVD: Yes; CVD: Yes 3.PVD: No; CVD: Yes 4.PVD: No; CVD: No

8. Correct Answer PVD (505) /CVD (525) 65 year old man admitted for CABG. H&P indicates a history of PAD: carotid stenosis, diabetic neuropathy, hypertension, prostate cancer treated with radiation and surgery and a surgical clipping of a cerebral aneurysm. How do you code PVD and CVD? 1.PVD: Yes; CVD: No 2.PVD: Yes; CVD: Yes 3.PVD: No; CVD: Yes 4.PVD: No; CVD: No

9. www.premiersurgical.com Coded Separately: CVD (525)  carotid  CVA  cerebral aneurysm Thoracic (510) PAD (505) upper extremity Abdominal renal mesenteric lower extremity

10. Audience Question CVA (530) The patient is admitted to the medical service with stroke like symptoms. His workup revealed aortic valve endocarditis and CVA due to septic emboli. He is treated with antibiotics for 2 weeks then taken to surgery for AVR. How do you code Prior CVA? 1. Yes 2. No

11. Correct Answer CVA (530) The patient is admitted to the medical service with stroke like symptoms. His workup revealed aortic valve endocarditis and CVA due to septic emboli. He is treated with antibiotics for 2 weeks then taken to surgery for AVR. How do you code Prior CVA? 1. Yes 2. No Patient had an embolic stroke prior to surgery and this should be captured in the risk factor section

12. Audience Question Last Creatinine Level (585) The Preoperative Creatinine recorded closest to surgery is 1.06 How do you record Last Creatinine Level? (585) 1. 1.1 2. 1.06

13. Correct Answer Last Creatinine Level (585) The Preoperative Creatinine recorded closed to surgery is 1.06 How do you record Last Creatinine Level? (585) 1. 1.1 2. 1.06 The specification manual for PREOP Cr. shows 2 places after the decimal LowValue: 0.10 HighValue: 30.00 Code as reported. Do not ‘round up’ Please note Postop Cr is only 1 place after the decimal

14. Audience Question Previous PCI: Indication for surgery (785) How do you code Previous PCI Indication for Surgery? 1. Yes, PCI complication 2. Yes, PCI failure without clinical deterioration 3. Yes, PCI failure with clinical deterioration 4. Yes, PCI for STEMI multi- vessel disease Patient had a stent placed to his mid RCA in 2014. He was admitted to your hospital with a ST elevation MI (STEMI) and was taken emergently to the cath lab where a balloon angioplasty was performed on his occluded proximal LAD. A stent could not be passed. PLAD 100% stenosis reduced to 80%. Stable without chest pain after PCI. Referred for CABG LIMA - LAD. RCA stent patent. LM no disease. CX 20%.

15. Correct Answer Previous PCI: Indication for surgery (785) How do you code Previous PCI Indication for Surgery? 2. Yes, PCI failure without clinical deterioration Patient had a stent placed to his mid RCA in 2014. He was admitted to your hospital with a ST elevation MI (STEMI) and was taken emergently to the cath lab where a balloon angioplasty was performed on his occluded proximal LAD. A stent could not be passed. PLAD 100% stenosis reduced to 80%. Stable without chest pain after PCI. RCA stent patent. LM no disease. CX 20%. Had LIMA – LAD the next day. PCI failure without clinical deterioration ‐ PCI failed to yield expected and/or desired results, patient condition did not deteriorate, includes attempts to cross with the wire but unsuccessful

16. PCI Interval in this case relates to the most recent PCI to surgery, not the timing of the stent placed in 2014 Prior Coronary Intervention PCI can be:  Angioplasty  Stent  Angioplasty and stent  Thrombectomy  Attempted PCI http://www.heart-specialist.org/angioplasty.html

17. Clarification When there is a history of prior stent and no stent during this admission, code the prior stent in seq 790: PCI Interval: is time between last PCI and surgery Previous PCI:  Yes  No (If Yes →) PCI Performed Within This Episode Of Care:  Yes, at this facility  Yes, at some other acute care facility  No Indication for Surgery:  PCI Complication  PCI Failure without Clinical Deterioration  PCI Failure with Clinical Deterioration  PCI/Surgery Staged (not STEMI)  PCI for STEMI, multivessel disease  Other PCI Stent:  Yes  No Seq 790 (If Yes →) Stent Type:  Bare metal  Drug-eluting  Bioresorbable  Multiple  Unknown PCI Interval:  6 Hours

18. Audience Question Cardiac symptoms at the time of admission (895) Anginal Class (905) Patient presents to an outside hospital on 7/1/15 complaining of chest pain that has been occurring over the last 3 days with activities such as walking. He states that when he stops and rests that the pain goes away. He is diagnosed with NSTEMI and transferred to your hospital on 7/5/15. CT surgery sees patient later that day and schedules surgery for the next morning. How do you code Cardiac Symptoms at the time of admission? And Anginal Class? 1. No symptoms, Class II 2. Stable Angina, Class III 3. Unstable Angina, Class IV 4. NSTEMI, Class III 5. ST elevation MI, Class IV 6. Anginal Equivalent, Class IV 7. Other, Class IV

19. Cardiac Presentation/Symptoms: (Choose one from the list below for each column  ) At time of this admission: CardSympTimeOfAdm (895) No Symptoms Stable Angina Unstable Angina Non-ST Elevation MI (Non-STEMI) ST Elevation MI (STEMI) Angina Equivalent Other Anginal Classification Within 2 weeks:  CCS Class 0  CCS Class I  CCS Class II  CCS Class III  CCS Class IV AnginalClass (905) Patient presents for this episode of care with NSTEMI. When coding cardiac presentation on admission, transfer from one facility to another is considered the same episode of care. Class III angina – marked limitation of ordinary activity (for example, angina occurs with walking 1 or 2 blocks on the level or climbing 1 flight of stairs in normal conditions and at a normal pace. Chest pain is relieved with rest. If there is no documentation of anginal class or any description of what causes the angina in the chart – leave anginal class blank. 4

20. Audience Question Cardiac Symptoms at time of surgery (900) Anginal Class (905) How do you code Cardiac Symptoms at the Time Of Surgery and Anginal Class? 1. Unstable Angina, Class IV 2. NSTEMI, Class III 3. STEMI, Class IV 4. NSTEMI, Class IV 5. STEMI, Class II 6. NSTEMI, Class II Nursing note: Patient completing first shower in prep for CABG in AM, developed chest pain and SOB. Assisted patient back to bed. EKG obtained. CT surgeon notified. Heparin drip started, Morphine 4 mg IV given and patient continues to complain of severe chest pain. CT surgeon arrives and documents - The patient who was initially scheduled for surgery the next day began having severe chest pain unrelenting and unrelieved with medications. EKG demonstrated ST elevation. Acute MI. Proceed with emergent surgery.

21. Correct Answer Cardiac Symptoms at time of surgery (900) Anginal Class (905) How do you code Cardiac Symptoms at the Time Of Surgery and Anginal Class? 1. Unstable Angina, Class IV 2. Non-ST elevation, Class III 3. STEMI, Class IV 4. NSTEMI, Class IV 5. STEMI, Class II 6. NSTEMI, Class II Nursing note 2200 evening before surgery - Patient completing first shower in prep for CABG in AM, developed chest pain and SOB. Assisted patient back to bed. EKG obtained. CT surgeon notified. Heparin drip started as ordered. Morphine 4 mg IV given and patient continues to complain of severe chest pain. CT surgeon arrives and documents - The patient who was initially scheduled for surgery the next day began having severe chest pain unrelenting and unrelieved with medications. EKG demonstrated ST elevation. Acute MI. Proceed with emergent surgery.

22. Rationale Patient developed ST elevation MI prior to surgery - The intent is to capture changes between admission and surgery; whether a patient improves or deteriorates. If the patient did not improve or deteriorate between admission and surgery, the code will most often be the same. A word about Class IV Angina - All other classes of pain go away with rest. Class IV angina – Pain did not subside with rest and/or medications. Inability to perform any physical activity without discomfort

23. Audience Question Cardiac Symptoms at time of admission (895) & Cardiac Symptoms at time of surgery (900) Patient presents with GI bleed, severe anemia, prolonged chest pain at rest and NSTEMI on 7/10/15. The Patient is stabilized over the next few days. He has LHC on 7/15/15 that shows severe 3V disease. CT surgery is consulted. The patient has CABG surgery on 7/18/15. How would you code Cardiac Symptoms: At the time of Admission and Time of surgery? 1. NSTEMI, no symptoms 2. NSTEMI, Stable Angina 3. NSTEMI, Unstable Angina 4. NSTEMI, NSTEMI

24. Correct Answer Cardiac Symptoms at time of admission (895) & Cardiac Symptoms at time of surgery (900) Patient presents with GI bleed, severe anemia, prolonged chest pain at rest and NSTEMI on 7/10/15. The Patient is stabilized over the next few days. He has LHC on 7/15/15 that shows severe 3V disease. CT surgery is consulted. The patient has CABG surgery on 7/18/15. How would you Cardiac Symptoms: At the time of Admission and Time of surgery? 3. NSTEMI, Unstable Angina If the patient presents with STEMI or NSTEMI, they should be coded as such in both sequence numbers 895 and 900 unless the patient remains in the hospital longer than 7 days prior to surgery and in that case presentation at the time of admission would be STEMI or NSTEMI and at the time of surgery would be coded as unstable angina.

25. Audience Question Heart failure within 2 weeks: CHF (910) Patient has severe Mitral Stenosis and is being electively admitted for MVR. H&P states that the patient is SOB with exertion and has a history of CHF with an EF of 35%. CHF functional class III. How do you code for Seq # 910 – CHF within 2 weeks of surgery? 1. Yes 2. No

26. Correct Answer Heart failure within 2 weeks: CHF (910) Patient has severe Mitral Stenosis and is being electively admitted for MVR. H&P states that the patient is SOB with exertion and has a history of CHF with an EF of 35%. CHF functional class III. How do you code for Seq # 910 – CHF within 2 weeks of surgery? 1. Yes 2. No

27. Audience Question Heart failure within 2 weeks: CHF (910) Patient has a functional status of Class III – not an acute decompensation. The intent is to capture the patient's actual status in the weeks before surgery, the new diagnosis or exacerbation of an existing heart failure condition. DO NOT code stable or asymptomatic compensated failure or patients whose symptoms improved after medical therapy. A low ejection fraction (EF) without clinical presentation does not qualify for history of heart failure

28. Audience Question Cardiogenic Shock 930 Patient presents with STEMI and is taken to Cath lab emergently. Cardiologist documents “Severe 3 vessel disease. Recommend emergent CABG. IABP placed for USA”. Patient transported to OR hemodynamically stable. Patient is on no pressors and his lowest BP in cath lab was 95/50. Cardiac surgeon documents in his indication for surgery “Patient with cardiogenic shock on 2 pressor agents and IABP requiring emergent surgery” Anesthesia documents SBP 100 – 110 prior to incision and no vasopressor medications at time of incision. How do you code for Cardiogenic Shock? 1.Yes, at the time of procedure 2. No

29. Correct Answer Cardiogenic Shock 930 Patient presents with STEMI and is taken to Cath lab emergently. Cardiologist documents “Severe 3 vessel disease. Recommend emergent CABG. IABP placed for USA. Patient transported to OR hemodynamically stable. Patient is on no pressors and his lowest BP in cath lab was 95/50”. Cardiac surgeon documents in his indication for surgery “Patient with cardiogenic shock on 2 pressor agents and IABP requiring emergent surgery” Anesthesia documents SBP 100 – 110 prior to incision and no vasopressor medications at time of incision. How do you code for Cardiogenic Shock? 1. Yes 2. No

30. Rationale Cardiogenic shock is defined as a sustained (>30 min) episode of hypoperfusion evidenced by systolic blood pressure <90 mm Hg and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support (e.g., IABP, extracorporeal circulation, VADs) to maintain blood pressure In this scenario, the patient did not have a sustained episode of hypoperfusion. His IABP was put in for USA and he was on NO vasopressor agents prior to incision. The data definition must be met in order to code cardiogenic shock.

31. Audience Question Arrhythmia: AFib (980) Patient has a history of paroxysmal Atrial fibrillation that was successfully treated with ablation 2 months ago. How do you code history of arrhythmia: atrial fibrillation? 1. None 2. Paroxysmal 3. Continuous/Persistent

32. Correct Answer Arrhythmia AFib (980) Indicate whether the patient has a history of a cardiac rhythm disturbance before the start of the operative procedure which includes the institution of anesthetic management. The arrhythmia must have been treated. Treatment may include: Ablation therapy ‐ surgical and/or catheter based Arrhythmia:  Yes  No  Unknown Arrhythmia (945) (If Yes →)(Choose one response for each rhythm below  ) VTach/VFib ArrhythVV Sick Sinus Syndrome ArrhythSSS AFlutter ArrhythAFlutter Second Degree Heart Block ArrhythSecond Third Degree Heart Block ArrhythThird None Remote (> 30 days preop) Recent (<= 30 days preop) (If Yes →)Permanently Paced Rhythm: ArrhythPPaced (975)  Yes  No Atrial Fibrillation: ArrhythAFib (980)  None  Paroxysmal  Continuous/Persistent If Continuous/persistent→ Indicate duration  ≤ one year  > one year  unknown ArrhythAFibDur (985)

33. Definition: Indicate whether the patient received thrombolytics within 48 hrs. preoperatively. Yes – capture….within 48 hrs No – Pt didn’t receive Thrombolytics within 24 hrs. preceding surgery G. Preoperative Medications MedicationTimeframeAdministration Thrombolytics MedThrom (1140) Within 48 hours  Yes  No Training Manual Clarification Seq #1140 Typo: should be 48 hrs

34. Audience Question Pre-op Med Long-acting Nitrate Therapy (1110) Pt. comes into the hospital and is placed on Nitroglycerin 2% Topical Ointment and received the medication for 4 days before surgery. The patient wasn’t on this medication at home How do you code: Pre-op med Long-acting Nitrate prior to surgery? 1)Yes 2)No 3)Contraindicated 4)Unknown www.google.com/search?q=nitroglycerin+ointment

35. Correct Answer: Pre-op Med Long-acting Nitrate Therapy (1110) Pt. comes into the hospital and is placed on Nitroglycerin 2% Topical Ointment and received the medication for 4 days before surgery. The patient wasn’t on this medication at home How do you code pre-op med Long-acting Nitrate prior to surgery? 2) No

36. Medication timing clarification Capture medications that are prescribed on a regular schedule and are presumed to be at a therapeutic level, for at least 2 weeks preceding surgery (entry into the OR) If home medication was discontinued after admission, code Yes: Intent is to capture appropriateness of care regardless of how many days in hospital pre-op without the medication. Appropriate medication therapy was attempted prior to surgical intervention.

37. Audience Question Anticoagulants (1040) The patient received both unfractionated heparin and Lovenox within 48 hours of surgery How should you code Anticoagulants? 1)Heparin (unfractionated) 2)Heparin (Low Molecular) 3)Other

38. Correct Answer Anticoagulants (1040) The patient received both unfractionated heparin and Lovenox within 48 hours of surgery How should you code Anticoagulants? 1)Heparin (unfractionated) 2)Heparin (Low Molecular) 3)Other

39. Rationale Half life IV UFH 45 min Half Life LMWH 4-5 hr.s

40. Section H – Hemodynamics and Cath

41. Audience Question Stent: Present (1205-1505) Patient had a PCI / Stent to the RCA on a previous admission and is readmitted 2 to 3 months later for surgery following failed medical therapy of known remaining CAD. The LHC is not repeated. PCI procedure from 2 months ago documents 80% RCA stenosis reduced to 0% stenosis after successful PCI and stent placement. How would you code Stents to Left Main, LAD, Circumflex, and RCA? 1. LM, LAD, CX stents not documented. RCA stent patent. 2. LM, LAD, CX stents leave blank. RCA stent patent. 3. LM, LAD, CX and RCA stents not documented.

42. Correct Answer Stent Present (1205-1505) Patient had a PCI / Stent to the RCA on a previous admission and is readmitted 2 to 3 months later for surgery following failed medical therapy of known remaining CAD. The LHC is not repeated. PCI procedure from 2 months ago documents 80% RCA stenosis reduced to 0% stenosis after successful PCI and stent placement. How would you code Stents to Left Main, LAD, Circumflex, and RCA? 2. LM, LAD, CX stents leave blank. RCA stent patent.

43. Rationale LHC was not repeated, so rely on information you have from latest coronary angiogram. In this case, the RCA stent was patent. Do not use ‘not documented’ for vessels that do not have stents placed in them. Leave these fields blank if there is no evidence that the patient had a stent in those vessels. ‘Not Documented ‘should be used for vessels that have known stents, but there is no documentation if they are patent or not. The same applies to previous grafts for sequence # 1200-1500

44. Seq # 1590, 1595, 1600 aortic insufficiency, aortic valve disease and aortic stenosis? 73 year old woman admitted for elective CABG. The Echo report indicates the following: Aortic Valve: Probably Tri- leaflet, moderately thickened, mildly calcified leaflets. Doppler: Mild to Moderate Regurgitation How do you code aortic insufficiency, aortic valve disease and aortic stenosis? 1.Moderate AI; Yes Aortic disease; Yes Aortic Stenosis 2. Mild AI. No Aortic disease. No stenosis. 3. Moderate AI. Yes Aortic disease. No stenosis. 4. Mild AI. Yes Aortic Disease. No stenosis. https:// intermountainhealthcare.org/services/heart-care/conditions/aortic-valve-stenosis /

45. Aortic Valve: Probably Tri-leaflet, moderately thickened, mildly calcified leaflets. Doppler: Mild to Moderate Regurgitation Aortic Valve Aortic Insufficiency:  None  Trivial/Trace  Mild  Moderate  Severe  Not Documented VDInsufA (1590) Aortic Valve Disease: VDAort (1595)  Yes  No (If Yes→ ) Aortic Stenosis:  Yes  No (If Yes→) Hemodynamic/Echo data available:  Yes  No 3. Moderate AI Aortic disease Yes No stenosis.

46. Rationale Enter the highest level of insufficiency recorded in the chart. "Mild to Moderate" should be coded as "Moderate". The valve should be coded as being diseased if there is mild, moderate or severe insufficiency. Aortic stenosis (AS) is the narrowing of the exit of the left ventricle of the heart such that problems result. Moderately thickened, mildly calcified leaflets do not indicate that the valve is stenotic.

47. Mitral Insufficiency 1680 Mitral Stenosis 1690 Mitral Valve Functional Class 1715 The Echo report indicates the following: Mitral Valve: Mild sclerosis. Mild prolapse Doppler: Moderate regurgitation How do you code mitral Insufficiency, mitral stenosis and Carpentier Mitral leaflet motion classification? 1. Moderate MI. No Stenosis. MV functional class not documented. 2. Moderate MI. Yes Mitral Stenosis. MV functional class Type II 3. Moderate MI. No Stenosis. MV functional class Type II 4. Moderate MI. Yes Mitral Stenosis. MV functional class not documented.

48. Mitral Insufficiency 1680 Mitral Stenosis 1690 Mitral Valve Functional Class 1715 The Echo report indicates the following: Mitral Valve: Mild sclerosis. Mild prolapse Doppler: Moderate regurgitation How do you code mitral Insufficiency, mitral stenosis and Carpentier Mitral leaflet motion classification? 3) Moderate MI No Stenosis MV functional class Type II

49. Rationale Sclerosis does not indicate stenosis. Sclerosis derives from the Greek meaning thickened or hardened Mitral stenosis is a valvular heart disease characterized by the narrowing of the orifice due to rigid, stiff or thickened leaflets of the mitral valve. MV functional Class - Prolapse can cause excess leaflet motion

50. Tricuspid valve insufficiency 1775 Tricuspid valve stenosis 1785 The Echo report indicates the following: Tricuspid Valve: The valve appears to be grossly normal. How do you code tricuspid insufficiency and tricuspid stenosis? 1. Insufficiency Not Documented; No Stenosis 2.No Insufficiency; No Stenosis

51. Tricuspid valve insufficiency 1775 Tricuspid valve stenosis 1785 The Echo report indicates the following: Tricuspid Valve: The valve appears to be grossly normal. How do you code tricuspid insufficiency and tricuspid stenosis? 1. Insufficiency Not Documented; No Stenosis 2. No Insufficiency; No Stenosis. Rationale: Normal: code as no disease vs not documented

52. Audience Question Pulmonic Valve insufficiency (1820) The Echo report indicates the following: Pulmonic Valve: Not well visualized. Physiologic regurgitation How do you code pulmonic valve insufficiency? 1. None 2. Trivial/Trace 3. Mild 4. Not documented

53. Correct Answer Pulmonic Valve insufficiency (1820) The Echo report indicates the following: Pulmonic Valve: Not well visualized. Physiologic regurgitation How do you code pulmonic valve insufficiency? 1. None Rationale: Over 90 % of the normal population has trivial to mild pulmonary regurgitation (PR) detected by color Doppler echocardiogram. This is what we call physiologic PR and is an incidental finding when the patient is undergoing a color Doppler echocardiogram for other reasons. This type of PR does not need any type of follow-up or intervention, as the pulmonary valve is normal.

54. If ECHO NOT performed Aortic Valve Aortic Insufficiency:  None  Trivial/Trace  Mild  Moderate  Severe  Not Documented Aortic Valve Disease:  Yes  No (If Yes→ )Aortic Stenosis:  Yes  No (If Yes→) Hemodynamic/Echo data available:  Yes  No (If Yes ↓) Smallest Aortic Valve Area:) ________ cm 2 Highest Mean Gradient: ________ mmHg For AI, the best answer is not documented. Answering ‘None’ would indicate that the echo was done and there was no insufficiency. There is not an option to select Not Documented for Aortic Valve Disease. When an echo is not done, the best answer is NO if there is no other documentation in the medical record that the patient has aortic valve disease.

55. Aortic Valve velocities reported as ‘normal’ How do you code Aortic Insufficiency? Aortic Valve Aortic Insufficiency:  None  Trivial/Trace  Mild  Moderate  Severe  Not Documented Aortic Valve Disease:  Yes  No (If Yes→ )Aortic Stenosis:  Yes  No (If Yes→) Hemodynamic/Echo data available:  Yes  No (If Yes ↓) Smallest Aortic Valve Area:) ________ cm 2 Highest Mean Gradient: ________ mmHg An increase in valve velocities may indicate increasing stenosis and they may also indicate increasing insufficiency- velocities are an indirect indicator - you can’t say for sure that that there is no insufficiency with normal velocities the best answer is Not Documented.

56. For Valve Insufficiency  None means you looked and there is no insufficiency  Also Physiologic Regurgitation and No Significant Regurgitation  Not documented means the procedure was either not done or the results are not recorded  Also Valve Not Visualized

57. When Numerical Values are used instead of descriptive terms Numerical ValueValue Insufficiency 0None 1+Trace/trivial 2+Mild 3+Moderate 4+Severe

58. Section L – Mechanical Assist Devices

59. Pt comes in as STEMI and IABP is placed. After becoming hemodynamically stable, the IABP is discontinued two days before surgery. Intraoperatively an IABP is place to wean from CPB. How do you code IABP When? 1.IABP Yes; When: Pre-op 2.IABP Yes; When: Pre-op and Intra-op 3.IABP Yes; When Intra-op Audience Question IABP When 3730

60. Pt comes in as STEMI and IABP is placed. After becoming hemodynamically stable, the IABP is discontinued two days before surgery. Intraoperatively an IABP is place to wean from CPB. How do you code IABP When? 3. IABP Yes; When Intra-op Correct Answer IABP When 3730 www.google.com/search?q=intra+aortic+balloon+pump&espv=2&biw=1600&bih

61. Rationale IABP When 3730 The intent of this field is to capture if the patient goes to surgery with an IABP in place (pre-op), has one inserted during surgery, or has one inserted post-operatively. In this case, the initial IABP was discontinued prior to surgery, therefore it should not be captured. Code the IABP “closest to surgery”