Effective January 1, 2019
Pacemaker, ID, and IM
Evaluatons
2019 Rembursement Overvew
Pacemaker
Device Monitoring
Common CPT
®
Codes and National Average Medicare Payment
2
Any # of
Leads
Single
Lead
Dual
Lead
Multiple
Lead
93279 93280 9328193288
93294 93296 93293
93286
(In-Person)
Programming
Evaluation
(In-Person)
Interrogation
Evaluation
Transtelephonic
Rhythm Strip
Evaluation
Remote
Interrogation
Evaluation
Any # of
Leads
Any # of
Leads
Any # of
Leads
In-Person
Remote
In-Person
Includes Programming MRI AutoDetect
Technical
Professional
(In-Person)
Peri Procedural
Evaluation
3
CPT Code CPT Code Definition
2019 Medicare
Total
RVUs
1
Avg. Pymt.
2
(In-Person)
Interrogation
Evaluation
93288
Interrogation
device evaluation (in person) with analysis, review and
report by a physician or other qualified health care professional,
includes connection, recording and disconnection per patient
encounter;
single, dual, or multiple
pacemaker system
1.25 $45.05
93288-26
(Professional Service Only)
0.61 $21.98
(In-Person)
Programming
Evaluation
93279
Programming
evaluation (in person) with iterative adjustment of
the implantable device to test the function of the device and select
optimal permanent programmed values with analysis, review and
report by a physician or other qualified health care professional;
single lead
pacemaker system
1.56 $56.22
93279-26
(Professional Service Only)
0.92 $33.16
93280
Programming
device evaluation (in person) with iterative adjustment
of the implantable device to test the function of the device and select
optimal permanent programmed values with analysis, review and
report by a physician or other qualified health care professional;
dual
lead
pacemaker system
1.83 $65.95
93280-26
(Professional Service Only)
1.09 $39.28
93281
Programming
device evaluation (in person) with iterative adjustment
of the implantable device to test the function of the device and select
optimal permanent programmed values with analysis, review and
report by a physician or other qualified health care professional;
multiple lead
pacemaker system
1.97 $71.00
93281-26
(Professional Service Only)
1.22 $43.97
Remote
Interrogation
Evaluation
Per 90 Days
93294
Interrogation
device evaluation(s) (remote), up to 90 days;
single,
dual, or multiple lead
pacemaker system with interim analysis,
review(s) and report(s) by a physician or other qualified health care
professional
0.87 $31.35
93296
Interrogation
device evaluation(s) (remote), up to 90 days
single, dual, or multiple lead
pacemaker system or implantable
defibrillator system, remote data acquisition(s), receipt of
transmissions and technician review, technical support and
distribution of results
0.72 $25.95
Transtelephonic
Rhythm Strip
Evaluation
Per 90 Days
93293
Transtelephonic rhythm strip pacemaker evaluation(s)
single, dual
or multiple lead
pacemaker system, includes recording with and
without magnet application with analysis, review and report(s) by a
physician or other qualified health care professional, up to 90 days
1.48 $53.34
93293-26
(Professional Service Only)
0.43 $15.50
(In-Person)
Peri-Procedural
Interrogation
3
93286
Peri-procedural device evaluation (in person) and
programming
of device device system parameters
before or after
a surgery,
procedure, or test with analysis, review and report by a physician or
other qualified health care professional;
single, dual, or multiple
lead
pacemaker system
0.99 $35.68
93286-26
(Professional Service Only)
0.43 $19.50
1
RVU=Relative Value Unit
2
Based on 2019 Medicare RVU Conversion Factor = $36.04
3
93286 is the appropriate code for programming MRI AutoDetect on in pacemakers in the peri-procedural setting
(e.g., cardiologist's office)
CPT codes and descriptors are copyright 2019 American Medical Association - All rights reserved. Applicable FARS/DFARS apply.
ICD
*
Device Monitoring
Common CPT
®
Codes and National Average Medicare Payments
4
93282 93283 9328493289
93295 93296
93287
Remote
Interrogation
Evaluation
Any # of
Leads
Any # of
Leads
(In-Person)
Peri Procedural
Evaluation
In-PersonRemote
Technical
Professional
93287
Any # of
Leads
Single
Lead
Dual
Lead
Multiple
Lead
(In-Person)
Programming
Evaluation
(In-Person)
Interrogation
Evaluation
*Implantable Cardioverter-Defibrillator
In-Person
Includes Programming MRI AutoDetect
5
CPT Code CPT Code Definition
2019 Medicare
Total
RVUs
1
Avg. Pymt.
2
(In-Person)
Interrogation
Evaluation
93289
Interrogation
device evaluation (in person) with analysis, review and
report by a physician or other qualified health care professional,
includes connection, recording and disconnection per patient
encounter;
single, dual, or multiple lead
transvenous implantable
defibrillator system, including analysis of heart rhythm derived data
elements
1.70 $61.27
93289-26
(Professional Service Only)
1.06 $38.20
(In-Person)
Programming
Evaluation
93282
Programming
device evaluation (in person) with iterative adjustment
of the implantable device to test the function of the device and select
optimal permanent programmed values with analysis, review and
report by a physician or other qualified health care professional;
single
lead
transvenous implantable defibrillator system
1.90 $68.47
93282-26
(Professional Service Only)
1.21 $43.61
93283
Programming
device evaluation (in person) with iterative adjustment
of the implantable device to test the function of the device and select
optimal permanent programmed values with analysis, review and
report by a physician or other qualified health care professional;
dual
lead
transvenous implantable defibrillator system
2.39 $86.13
93283-26
(Professional Service Only)
1.64 $59.11
93284
Programming
device evaluation (in person) with iterative adjustment
of the implantable device to test the function of the device and select
optimal permanent programmed values with analysis, review and
report by a physician or other qualified health care professional;
multiple
lead
transvenous implantable defibrillator system
2.59 $93.34
93284-26
(Professional Service Only)
1.79 $64.51
Remote
Interrogation
Evaluation
Per 90 Days
93295
Interrogation
device evaluation(s) (remote), up to 90 days
single,
dual, or multiple lead
implantable defibrillator system with interim
analysis, review(s) and report(s) by a physician or other qualified
health care professional
1.22 $43.97
93296
Interrogation
device evaluation(s) (remote), up to 90 days
single,
dual, or multiple lead
pacemaker system or implantable defibrillator
system, remote data acquisition(s), receipt of transmissions and
technician review, technical support and distribution of results
0.72 $25.95
(In-Person)
Peri-Procedural
Interrogation
3
93287
Peri-procedural device evaluation (in person) and
programming
of
device system parameters
before or after
a surgery, procedure, or
test with analysis, review and report by a physician or other qualified
health care professional;
single, dual, or multiple lead
implantable
defibrillator system
1.22 $43.97
93287-26
(Professional Service Only)
0.66 $23.79
1
RVU=Relative Value Unit
2
Based on 2019 Medicare RVU Conversion Factor = $36.04
3
93287 is the appropriate code for programming MRI AutoDetect on in ICDs in the peri-procedural setting (e.g., cardiologist's office)
CPT codes and descriptors are copyright 2019 American Medical Association - All rights reserved. Applicable FARS/DFARS apply.
6
SCRM
*
Device Monitoring
Common CPT
®
Codes and National Average Medicare Payments
CPT Code CPT Code Definition
2019 Medicare
Total
RVUs
1
Avg. Pymt.
2
(In-Person)
Interrogation
Evaluation
93290
Interrogation
device evaluation (in person) with analysis, review and
report by a physician or other qualified health care professional,
includes connection, recording and disconnection per patient
encounter; implantable cardiovascular physiologic monitor system,
including analysis of 1 or more recorded physiologic cardiovascular
data elements from all internal and external sensors
1.19 $42.89
93290-26
(Professional Service Only)
0.62 $22.34
Remote
Interrogation
Evaluation
Per 30 Days
93298
Interrogation
device evaluation(s), (remote) up to 30 days;
subcutaneous cardiac rhythm monitor system, including analysis
of recorded heart rhythm data, analysis, review(s) and report(s) by a
physician or other qualified health care professional
0.75 $27.03
93299
Interrogation
device evaluation(s), (remote) up to 30 days; implantable
cardiovascular physiologic monitor system or subcutaneous
cardiac rhythm monitor system, remote data acquisition(s), receipt
of transmissions and technician review, technical support and
distribution of results
0.00
Determined
by Regional
Medicare
Administrative
Contractor
(MAC)
1
RVU - Relative Value Unit
2
Based on 2019 Medicare RVU Conversion Factor = $36.04
CPT codes and descriptors are copyright 2019 American Medical Association - All rights reserved. Applicable FARS/DFARS apply.
In-Person
Remote
Interrogation
93298 9329993290
Interrogation
*Subcutaneous Cardiac Rhythm Monitor
Technical
Professional
The following table contains a summary of common pacemaker, ICD, and SCRM device monitoring procedures.
Information includes CPT billing codes, CPT frequency rules, and 2019 Medicare unadjusted global payment
rates for physicians.
7
Procedure Device CPT Code
Total
RVUs
1
2019
Medicare
Payment
2
CPT Frequency
(In-Person)
Interrogation
Evaluation
Pacemaker
Any number of leads
93288 1.25 $45.05
Per encounter
ICD
Any number of leads
93289 1.70 $61.27
SCRM 93290 1.19 $42.89
(In-Person)
Programming
Evaluation
Pacemaker
Single lead
Dual lead
Multiple lead
93279
93280
93281
1.56
1.83
1.97
$56.22
$65.95
$71.00
Per encounter
ICD
Single lead
(note: includes BIOTRONIK DX ICD)
Dual lead
Multiple lead
93282
93283
93284
1.90
2.39
2.59
$68.47
$86.13
$93.34
S-ICD 93260 1.93 $69.56
Remote
Interrogation
Evaluation
Pacemaker
Any number of leads
93294
+
93296
1.59
$57.30
Not more than once
every 90 days
ICD
Any number of leads
93295
+
93296
1.98 $71.36
SCRM
93298
+
93299
Carrier Determined
Not more than once
every 30 days
(In-Person)
Peri-Procedural
Interrogation
Pacemaker
Any number of leads
93286 0.99 $35.68
Per encounter
(may bill for
both pre- and
post-procedure
evaluations)
ICD or S-ICD
Any number of leads
93287 1.22 $43.97
1
RVU=Relative Value Unit
2
Based on 2019 Medicare RVU Conversion Factor = $36.04
Pacemaker, ICD, and SCRM
Evaluations
Reimbursement Summary
Responses to Common Questions
8
The following information is based entirely on third party sources
including the Centers for Medicare and Medicaid Services (CMS),
the American Medical Association (AMA), the American College of
Cardiology (ACC), and the Heart Rhythm Society (HRS).
GLOBAL PERIOD
Q: Are device evaluations included in the 90-day surgical global
period following a device implant?
No. Pacemaker and ICD device evaluations are considered
diagnostic tests and therefore are not included in the 90-day
global period associated with a pacemaker or ICD implant
procedure. These procedures may be billed, beginning with
the day following the device implant. Device evaluations that
occur on the same day of surgery should not be billed.
REMOTE DEVICE MONITORING
Q: Can a physician bill for a remote evaluation every 90 days, or
up to four times a year?
Yes. CPT rules allow billing for this procedure no more than
once every 90 days.
Q: In order to bill for remote device monitoring does a physician
need to review a remote transmission every 90 days?
No. CPT rules only require that at least one remote
transmission be reviewed and documented in the medical
record at least once during the 90-day monitoring period. This
review can occur at any time after 30 days of monitoring has
occurred during the period. Unless otherwise required by an
insurance plan, it is not necessary to review and document
the transmission on a specific day such as the last day of the
period or day 90.
Q: Does a physician need to review a stored intracardiac
electrogram (IEGM) in order to bill for a remote interrogation
evaluation (CPT code 93294 or 93295)?
No. According to the American Medical Association (AMA)
CPT Advisors representing the Heart Rhythm Society (HRS),
the review and documentation of an ECG/rhythm strip is
not required in order to bill for remote interrogations of
pacemaker or ICDs.
Q: Can a physician bill for both remote monitoring and
transtelephonic monitoring of a pacemaker?
No. A transtelephonic rhythm strip evaluation (i.e., 93293)
may not be billed during the same 90-day period of a remote
pacemaker evaluation (i.e., 93294 and 93296).
Q: Can a physician bill for a remote evaluation each time that
information is retrieved and reviewed by a physician or
qualified health care professional?
No. It is anticipated that multiple device evaluations may be
required within each remote monitoring period. CPT rules
allow physicians to bill for remote evaluations no more than
once every 90 days.
FREQUENCY OF IN-PERSON EVALUATIONS
Q: Has CMS published any Medicare frequency guidelines for
pacemaker or ICD evaluations?
Yes for pacemakers, but not specifically for ICDs. The most
recent guidelines for monitoring can be found in the Medicare
National Coverage Determinations Manual, Chapter 1, Part 1
(Section 20.8) https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf
Q: Can a physician bill for an in-person
programming
evaluation during the same 90-day period covered by a
remote evaluation?
Yes. A physician can bill for an in-person
programming
evaluation, but not an in-person
interrogation
evaluation.
Q: How often can a physician bill for an in-person device
programming
evaluation when a patient is being remotely
monitored?
There are currently no frequency limitations for in-person
device programming evaluations (i.e., 93279-93284). In
general, in-person device programming evaluations may be
performed as often as is medically necessary.
Q: Can a physician bill for an in-person pacemaker or ICD
battery check during the same period as for a remote device
evaluation?
No. If the in-person battery check involves
only
a passive
download of information from the device (e.g., using a
magnet), this procedure is classified as an
interrogation
evaluation (and not a programming evaluation), and therefore
it cannot be billed during the same period as a remote
evaluation.
Q: If remote monitoring is terminated at or near the
time that a device battery is depleted, or reaches Elective
Replacement Indicator (ERI) status, can a physician bill for
an in-person device interrogation evaluation each month
until the device is replaced?
Yes, if medically necessary. There are currently no frequency
restrictions for completing in-person pacemaker or ICD
interrogation evaluations (i.e., 93288 and 93289). However, in-
person interrogation evaluations are not billable if the patient
is on remote monitoring.
DOCUMENTATION
Q: Given that the information obtained from remote device
interrogations is stored on a computer, is there a need to
keep this information in the patient’s medical record?
Yes. It is the responsibility of the physician to maintain a copy
of the documentation specific to each billable service in the
patient's medical record.
9
Q: What information is needed in order to bill for a remote or
in-person
pacemaker interrogation
evaluation?
In order to bill for a pacemaker interrogation evaluation
(i.e., 93288, 93294 and 93296), stored and measured information
on the programmed parameters, lead(s) when present, battery,
capture and sensing function(s) when present and heart rhythm
must be evaluated. Therefore, a report showing this information
as well any notes that describe the procedure should be
documented in the patient's medical record.
Q: What information is needed in order to bill for an in-person
pacemaker programming
evaluation (CPT codes 93279-
93281)?
In order to bill for a pacemaker programming evaluation
(i.e., 93279-93281), stored and measured information on
the programmed parameters, lead(s) when present, battery,
capture and sensing function(s) when present, and heart
rhythm must be evaluated. Often, but not always, the sensor
rate response, lower and upper heart rates, AV intervals,
pacing voltage, and pulse duration, sensing value and
diagnostics will be adjusted during a programming evaluation.
Therefore, a report showing this information as well any notes
that describe the procedure should be documented in the
patient's medical record.
Q: What information is needed in order to bill for a remote or in-
person
ICD interrogation
evaluation (CPT code 93289, 93295
and 93296)?
In order to bill for an ICD device interrogation (i.e., 93289,
93295 and 93296), stored and measured information regarding
the programmed parameters, lead(s) when present, battery,
capture and sensing function(s) when present, presence or
absence of therapy for ventricular tachyarrhythmias and the
patient’s underlying heart rhythm must be evaluated. Therefore,
a reporting showing this information as well as any notes that
describe the procedure should be documented in the patient's
medical record.
Q: What information is needed in order to bill for a remote or
in-person
ICD programming
evaluation (CPT codes 93282-
93284)?
In order to bill for an ICD programming evaluation
(i.e., 93282 -93284), stored and measured information
regarding the programmed parameters, lead(s) when
present, battery, capture and sensing function(s) when
present, presence or absence of therapy for ventricular
tachyarrhythmias and the patient’s underlying heart rhythm
must be evaluated. Often, but not always, the sensor rate
response, lower and upper heart rates, AV intervals, pacing
voltage and pulse duration, sensing value, and diagnostics
will be adjusted during a programming evaluation. In
addition, ventricular tachycardia detection and therapies are
sometimes altered depending on the interrogated data and
the patient’s rhythm, symptoms, and condition. Therefore,
a report showing this information as well any notes that
describe the procedure should be documented in the patient's
medical record.
USE OF DEVICE REPRESENTATIVES
Q: Can a physician bill for the
technical
service of a remote
or in-person device evaluation if a device manufacturer
representative completes the entire service?
No, physicians would only bill for the professional component
of the service by appending a -26 modifier to the procedure
code. In order to bill Medicare for the technical service of a
procedure, physicians must either perform the procedure
or appropriately supervise qualified staff who complete the
procedure. In general, in-person device evaluations (CPT
codes 93279-84, 93288-90) require "direct supervision"
and remote device evaluations (CPT codes 93296, 93299)
require "general supervision" by a physician. According to
CMS claims processing guidelines, however, "supervision
requirements for physician billing is
not
met when the test
is administered by supplier personnel regardless of whether
the test is administered at the physician's office or at another
location". Providers should contact their local Medicare MAC
or other expert sources for additional clarification as needed.
OWNERSHIP OF EQUIPMENT
Q: Can a physician bill for the
technical
service of a pacemaker
or ICD device evaluation if the physician or facility does not
own the device interrogation and programming equipment?
Yes. The ownership of the device monitoring and programming
equipment is not the determining factor for deciding whether or
not a physician can bill for the technical service.
PATIENT EVALUATIONS
Q: Can a physician bill for a patient evaluation that occurs on the
same day as an in-person device evaluation?
Physicians may only bill for a patient evaluation (i.e., Evaluation
and Management procedure) on
the same
day as an in-person
device evaluation if the patient has symptoms that require
a distinct clinical assessment above and beyond the device
evaluation. A -25 modifier must be appended to the E/M
procedure code to identify the procedure as a significant and
separately identifiable service. Separate documentation of the
procedure must be included in the patient’s medical record.
PATIENT DIAGNOSIS CODES
Q: What ICD-10-CM
1
patient diagnosis code(s) should be used
for pacemaker and ICD device evaluations?
The following diagnosis codes are commonly used when a patient
does not have any symptoms or device complications:
Z95.0 Presence of cardiac pacemaker; Z95.810 Presence of
automatic (implantable) cardiac defibrillator; Z45.010 Encounter
for checking and testing of cardiac pacemaker pulse generator
[battery], Z45.018 Encounter for adjustment and management
of other part of cardiac pacemaker, or Z45.02 Encounter for
adjustment and management of automatic implantable cardiac
defibrillator. In general, codes Z95.0 and Z95.810 are used for
periodic, routine remote, and in-person device monitoring
evaluation, and Z45.010, Z45.018 and Z45.02 are used when the
device is reprogrammed or other adjustments are necessary.
If the patient has symptoms or a device complication, the
appropriate diagnosis code(s) that describes these conditions
should be used.
1
International Classification of Diseases, 10
th
Revision, Clinical Modification
10
SUBCUTANEOUS CARDIAC RHYTHM MONITORS
(SCRMS)
Q: What is a Subcutaneous Cardiac Rhythm Monitor (SCRM)?
A Subcutaneous Cardiac Rhythm Monitor, or SCRM, is a
new term used to describe medical devices that collect
longitudinal, physiologic cardiovascular data elements from
one or more internal or external
sensors. This information
can be used to assist physicians in managing
non-rhythm
related cardiac conditions, such as heart failure. An SCRM
may be an additional function of an implantable cardiac
device (e.g., a cardiac resynchronization therapy defibrillator
(CRT-D)) or a function of a stand-alone device.
Q: What type of data does a Subcutaneous Cardiac Rhythm
Monitor, or SCRM, collect?
Common data collected by
internal
SCRM sensors include
right ventricular pressure, left atrial pressure, respiratory rate,
and an index of lung water, such as transthoracic impedance.
Common data collected by
external
SCRM sensors include
blood pressure and body weight. The data are stored and
transmitted to the physician by either local telemetry or
remotely to an Internet-based file server or surveillance
technician.
Q: Can a physician bill for an SCRM evaluation in addition to the
ICD device evaluation?
Yes. The data and mechanisms used to monitor and control
heart rhythms such as sensing, pacing and tachycardia
detection are separate and distinct from the physiologic
data collected by SCRM sensors used to monitor patient
conditions. Therefore, the monitoring processes are also
intended to be distinct and separately billable events.
Q: Can a physician bill for reviewing the data when it is
collected from an ICD device while the patient is being
evaluated in person?
Yes. CPT code (93290) is used to describe an in-person
evaluation of an SCRM. This CPT code may be billed for each
medically necessary in-person SCRM evaluation.
Q: How often can physicians bill for an SCRM evaluation?
The CPT codes for remote SCRM evaluations (93298 & 93299)
can not be billed more than once every 30 days. Therefore, if
medically necessary, a physician may bill for remote SCRM
evaluations as often as every 31 days.
Q: What is the Medicare payment amount for CPT code 93299?
Neither CMS nor the American Medical Association (AMA)
CPT panel have assigned a national relative value unit (RVU)
for this billing code. Rather, payment rates are assigned
by the regional Medicare Administrative Contractor (MAC).
Payment rate varies significantly depending on the MAC.
Q: How much SCRM data must be reviewed by a physician
during each 30-day monitoring period?
CPT guidelines require that at least 10 days of data
be evaluated in order to use CPT codes 93298 and 93299.
PATIENT COPAY
Q: Are patients required to pay a copay each time a physician
submits a bill for an SCRM evaluation?
Yes. Patients with traditional Medicare insurance are
responsible for paying 20% of the Medicare-allowed payment
rate each time that a physician bills for an SCRM evaluation.
Many patients with Medicare insurance, however, purchase
a secondary insurance plan (called MediGap) that covers the
cost of all Medicare coinsurance, copays, and deductibles.
In this case, the physician may bill the patient's secondary
insurance plan to collect these fees. In addition, most health
insurance plans also require patients to pay a copay for
each physician service or office visit including remote device
evaluations.
GUIDELINES
Q: Do any health insurance plans have coverage policies for
SCRMs or transthoracic impedence evaluations?
To our knowledge, Medicare has not published any coverage
decisions for SCRMs or transthoracic impedance. Physicians
must determine whether or not the evaluation of SCRM data
is 'reasonable and necessary' as required by Medicare laws
and regulations. Some private insurers may have coverage
policies that apply to transthoracic impedance. Providers
should check with insurance plans to be sure they cover
SCRM procedures.
Q: Are there any published clinical guidelines related to SCRMs
or transthoracic impedence (TI)?
No. We are not aware of any clinical guidelines or standards
published by the Heart Failure Society of America (HFSA),
the American College of Cardiology (ACC), or from other
professional societies that include a clinical opinion on the
appropriate use of TI.
NEW - PROGRAMMING MRI AUTODETECT
Q: What codes should HCPs use when programming devices
into MRI AutoDetect mode in the peri-procedural setting?
BIOTRONIK cardiac implantable electronic devices (CIEDs)
with MRI AutoDetect capabilities will require an interrogation
and programming interaction prior to their entry into the MRI
suite. This interrogation can occur at any time up to 14 days
prior to the the planned MRI procedure and may be done in
any location where the following HCP normally interrogates
and programs devices. The correct CPR
®
codes to use for this
procedure are 93286 for pacemakers and 93287 for ICDs.
11
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Disclaimer: Reimbursement related information provided by BIOTRONIK is obtained from third party sources. This information is
provided for the convenience of the health care provider only and does not constitute reimbursement, legal or compliance advice.
Billing & coding information is subject to frequent and unexpected change, therefore BIOTRONIK recommends that users refer to the
information sources listed to verify accuracy prior to acting on the information provided herein. BIOTRONIK makes no representation
or warranty regarding this information or its accuracy, completeness or applicability and assumes no responsibility for updating this
information. BIOTRONIK specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance
on information in this document. BIOTRONIK strongly encourages health care providers to submit accurate and appropriate claims for
services and recommends that you consult directly with payers, certified reimbursement coding professionals, other reimbursement
experts, and/or legal counsel regarding all coding, coverage, and payment issues.
BIOTRONIK, Inc.
6024 Jean Road
Lake Oswego, OR 97035-5369
(800) 547-0394 (24-hour)
(800) 291-0470 (fax)
www.biotronik.com
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BR249r10 3/12/19
