How can the Gibbs energy change of a reaction can be calculated? Powered and implemented by FactSet Digital Solutions. The surgery requires a few small incisions and takes about an hour. About the Orthopedic Knee Team. [14], Chondrocyte implantation procedures (CCI), a cell-based articular cartilage repair procedure that aims to provide complete hyaline repair tissues for articular cartilage repair, have been posed by some as an alternative to microfracture surgery. This is then moved to the side so the surgeon can get to the knee joint behind it. Surgery of the knee, injury to the infrapatellar branch of the saphenous nerve, traumatic eczematous dermatitis is a neuropathic dermatitis specific to total knee arthroplasty (TKA), occurring around the healed surgical scar area. Arthroscopy (ahr-THROS-skuh-pee) is a procedure for diagnosing and treating joint problems. Based on the National Correct Coding Initiative Edits, codes 29879 and 29882 are not listed as being component to code 29881. Modifier 59 is defined as Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. These books contain exercises and tutorials to improve your practical skills, at all levels! CPT 20610 flags a NCCI Edit when billed with CPT 29880, 29876, and 29888. Or fastest delivery Tue, Feb 28. The lateral compartment revealed a complex tearing in the anterior and midlateral portions. Showing 1-25: ICD-10-CM Diagnosis Code M70.50 [convert to ICD-9-CM] Other bursitis of knee, unspecified knee. Surgical Arthoplasty of the Left Knee. www.cartilagehealth.com/acr.html, Dr. Richard Steadman: Pioneer in Cartilage Regeneration, "Bills looking for more balance on offense", "Microfracture knee surgery and its impact on the NBA", http://www.amjcaserep.com/index.php?/archives/article/855038, "Characterized Chondrocyte Implantation Results in Better Structural Repair When Treating Symptomatic Cartilage Defects of the Knee in a Randomized Controlled Trial Versus Microfracture", "The Daily Dime 3.17.07: 10 Drops of NBA Knowledge. 2012;470(10):2949-53. doi:10.1007/s11999-012-2383-7, Gerbino P. Lateral retinacular release and reconstruction. Limb-sparing extremity surgery is possible in more than 90 percent of situations involving sarcoma of the arms or legs. He and the team doctor decided he needed more time to rehab and he did not return until the 20062007 NBA season. How does a dielectric material also allow a greater voltage to be applied to a capacitor? If you have certain health risks, a more extensive evaluation may be necessary before your surgery. Anyone considering the surgery should only do so after consultation with an orthopedic surgeon. SALA" " of the left ankle. * 29875:20610 Misuse of column two code with column one code In terms of time, the clot takes about 8 to 15 weeks for conversion to fibrous tissue and is usually fibrocartilage by about four months post surgery, holding implications for the rehabilitation. Steadman slowly refined the procedure through research (including tests on horses). Adults of any age can be considered for a knee replacement, although most are carried out on people between the ages of 60 and 80. SARS" " of the right shoulder. Meniscus surgery is the surgical reconstruction or removal of a torn meniscus from your knee. Ann Transl Med. The compartments include the following components: * Medial: medial femoral condyle, medial tibial plateau, and medial meniscus, * Lateral: lateral femoral condyle, lateral tibial plateau, and lateral meniscus. As a patient at Reconstructive Orthopedics, you are always a partner in your medical care, never simply a subject of it. Before your surgery, a member of the anesthesia team will talk with you. More extensive operations may be needed in the future for these more severe conditions. Lose weight or maintain a healthy body weight. When your healthcare provider assesses your kneecap problems, he or she will look for several underlying problems with the mechanics of the kneecap. The surgery is quick (typically lasting between 30 and 90 minutes), minimally invasive, and can have a significantly shorter recovery time than an arthroplasty (knee replacement). 2023 Dotdash Media, Inc. All rights reserved, Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Knee Surg Sports Traumatol Arthroscop, 17, 607-616. The kneecap moves up and down in a groove on the end of the thigh bone as the knee bends. This was debrided with a shaver. Winfrey noted she first had a knee surgery in August of last year then another surgery on the opposite knee in November of last year. Therefore, if 29870-59, 29871-59, 29875-59 and/or 29884-59 is submitted with 29881both services reimburse separately or if 29870-LT, 29871-LT, 29875-LT and/or 29884-LT is submitted with 29881-RTboth services reimburse separately. Knee Replacement Surgery When a knee replacement is performed, the bone and cartilage on the end of the thigh bone (femur) and top of the shin bone (tibia) are removed. Accordingly, only the more extensive procedure, HCPCS/Procedure code 29881 should be reported. The rest of your knee is preserved. But when a knee injury or an underlying disease affects this harmony, patients complain of knee issues. The surgery is conducted with the aid of an arthroscope, which is a very small instrument guided by a lighted scope attached to a Arthroscopy is used to diagnose and treat a wide range of knee problems. [19], In June 2010, Grady Sizemore of the Cleveland Indians underwent microfracture surgery after injuring his left knee while diving back to first base earlier in the season. SALS" " of the left shoulder. If your provider does not obtain pre-certification prior to your knee arthroscopy, you will need to call the health plan and request pre-certification yourself. Other complications include infection and scar tissue formation.. During knee replacement, a surgeon cuts away the damaged bone and cartilage from your thighbone, shinbone and kneecap, and replaces it with an artificial joint. Patient has WC and Medicare insurance? Squats and deadlifts after knee surgery. The knee is thelargest joint in the body and a healthy knee is vital to performing most daily activities, according to AAOS. [15], Many notable professional athletes have undergone the procedure. During primary total knee arthroplasty (TKA), synovectomy as a part of the procedure has been recommended to relieve pain and inflammation of the synovium, but there is a controversy about it due to increased bleeding. All Rights Reserved to AMA. CELEBRITIES GET REAL ABOUT PLASTIC SURGERY: GOOD PLASTIC SURGERY, YOU CANT TELL'. As we have gained experience with this problem, surgeons have become better at selecting which patients are likely to benefit from a lateral release. Your first step in dealing with ongoing . A lateral release is a surgical procedure on the knee used to realign the kneecap (patella). Chronic inflammation eventually leads to cartilage damage. 2008 MayJun;11(3):34353. He returned to the court in March 2006 and initially appeared to have made a full recovery, but subsequently started feeling stiffness in both knees (his right knee had been overcompensating for the injured left knee). Roman History 600 BC - 146 BC. by Pridie drilling,[2] spongialization[3] abrasion[4] or microfracture causing the release of multipotent mesenchymal stem cells from the bone marrow, may heal with repair tissue consisting of fibrous tissue, fibrocartilage or hyaline-like cartilage. Over the past decades, surgeons have become much more selective in choosing the people who would benefit from the procedure. At Orlando Health Jewett Orthopedic Institute, our highly trained orthopedic specialists are experts in diagnosing and treating even the most complex knee problems. Insights Imaging. There are three dangerous underlying conditions associated with dark veins: Deep vein thrombosis: When a blood clot forms in one of the deep veins in your body. 500 results found. Based on the Complete Global Service Data for Orthopaedic Surgery, codes 29879 or 29882 are not listed as being included in the performance of 29881. Arthritis is the most common cause of chronic knee pain and disability, according to the AAOS. In this meta-analysis, the aim is to answer whether synovectomy should be performed routinely during TKA for symptomatic knee osteoarthritis (KOA). Knee arthroscopy - Knee arthroscopy can be used to treat a . Rationale EDIT. Partial knee replacement: Performed when arthritis affects only one side of the knee and the ligaments within the knee are strong. Vomiting after gastrointestinal tract surgery; Vomiting after gi surgery. When all components perform together "in harmony," the knee works normally. LIFE LESSONS FROM FLORIDA COACH WHO HELPED MAN WITH DOWN SYNDROME COMPETE IN IRONMAN TRIATHLON. What to Do If Your Orthopaedic Surgery Is Postponed. Media mogul Oprah Winfrey doesnt want to take her knees for granted ever again. In many areas, nonessential orthopaedic procedures that were postponed due to COVID-19 have resumed. Knee pain, stiffness or swelling can limit your movement and keep you from doing the things you love. Every day, I tried to hike more and do more," Winfrey said. Respondents Position Summary: The billed CPT of 29876 flags a NCCI Edit when billed with CPT 29888 and 29880. J Bone Joint Surg Br. The operative record shows that CPT 29876-59 was performed in the patellofemoral joint, and in the lateral and medial compartments. Modifier 59 is defined as Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Your surgeon will insert the arthroscope and surgical instruments through small incisions called portals. Operative Report, The medial compartment revealed an intact meniscus and articular surface. Surgery to repair a damaged knee meniscus is very common, but it may not help a lot of people, a study finds. This means you will not need to stay overnight at the hospital. That may be because some people benefit more than others, and doctors still don't know . Blood clots in the leg veins are one of the most common complications of knee replacement surgery. She noted the use of a medication calledtranexamic acid around the time of the operation helps control bleeding, which in turn can help with pain. Winfrey revealed this week that she underwent right and leftknee replacements last year. Appointments 216.444.2606. During the procedure, the orthopedic surgeon makes small incisions or portals in the affected joint, and then inserts a tiny camera and fiber optics to light the interior space. Replacement of the kneecap: In this . Anthem Central Region bundles 29870, 29871, 29875 and 29884 as incidental with 29881; bundles 29870-50, 29871-50, 29875-50 and 29884-50 as incidental with 29881-50; bundles 29870-LT, 29871- LT, 29875-LT and 29884-LT as incidental with 29881-LT and bundles 29870-RT, 29871-RT, 29875- RT and 29884-RT as incidental with 29881-RT. The pain that patients feel after the procedure can be "substantial after the operation until the legs adjust to being straightened," Lajam told Fox News Digital. Please reach out and we would do the investigation and remove the article. A patient may return to driving when full use of the leg has returned and the car can be safely handled. [5] The quality of the repair tissue after these "bone marrow stimulating techniques" depends on various factors including the species and age of the individual, the size and localization of the articular cartilage defect, the surgical technique, e.g., how the subchondral bone plate is treated, and the postoperative rehabilitation protocol. Since the first knee replacement surgery was performed in 1968, medical advances have greatly improved the effectiveness of the procedure, according to the American Academy of Orthopaedic Surgeons (AAOS). For information:Questions and Answers for Patients Regarding Elective Surgery and COVID-19. ICD-10-CM Diagnosis Code K91.0 [convert to ICD-9-CM] Vomiting following gastrointestinal surgery. Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions, rather than the larger incision needed for open surgery. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Senescence-Associated Receptor-Like Kinase. The hospital or surgery center will contact you ahead of time to provide specific details about your procedure. Arthroscopy is commonly used to diagnose and treat problems that damage the articular cartilage, ligaments, and other structures around the joint. Lee Albert NMT (Author), sark (Foreword), Megha Nancy Buttenheim MA (Foreword) 1,023 ratings Paperback $35.00 39 Used from $4.86 6 New from $28.27 Don't let chronic pain control you! Quotes displayed in real-time or delayed by at least 15 minutes. This helps your orthopaedic surgeon see the structures inside your knee clearly and in great detail. * 29881:29870 Procedure Separate Procedure definition Total knee replacement (TKR): Surgery involves the replacement of both sides of the knee joint. * Reimbursement is recommended for Procedure 29881. But when a knee injury or an underlying disease affects the harmony, patients complain of knee issues. Sometimes the metal parts may be "cemented or press fit" into the bone. In many cases, special devices are used to anchor stitches into bone. The lateral compartment refers to the outer knee. When all the knee components perform together "in harmony," the knee works normally, AAOS noted on its website. Sauk Prairie Healthcare provides robotic-assisted knee replacement surgery using the the VELYS Robotic-Assisted Solution. The operative report did not document a separate anatomical site or encounter to substantiate separate reimbursement for Procedure 29875. Specialized instruments are used for tasks like shaving, cutting, grasping, and meniscal repair. "My appreciation for every organ and every limb has just expanded exponentially," she told a class entitled "The Life You Want." Very few case reports exist in orthopaedic literature regarding this rare skin complication after TKA. Anthem Central Region does not bundle 29879 or 29882 with 29881. For the reasons stated above, the Division finds that the requestor has established that additional reimbursement is not due. Surgery. Specifically, chondroplasty is performed to smooth damaged cartilage in the knee in order to lessen friction in the joint. Callback requests are currently unavailable. February 2023 (pdf) Download 08/01/2021 Sark Vaccination Program Information (pdf) Download COVID booster and flu jab (pdf) Download Surgery for appointments only Mon, Tue, Thur & Fri: 8.30am-1pm booked appointments only. SARK" " of the right knee. 2019;10(1):65. doi:10.1186/s13244-019-0755-1, Fonseca L, Kawatake E, Pochini A. Lateral patellar retinacular release: changes over the last ten years. Most patients need crutches or other assistance after arthroscopic surgery. Your out of pocket costs will depend on the type of insurance that you have. diagnose the cause of your joint instability, pain, or dysfunction. If surgical treatment is needed, your surgeon will insert tiny instruments through other small incisions. ", CLICK HERE TO SIGN UP FOR OUR LIFESTYLE NEWSLETTER. The operative record shows that a steroid anesthetic injection was given through the medial portal. The HCPCS/Procedure codes corresponding to more extensive procedures always include the HCPCS/Procedure codes corresponding to less complex procedures. Partial knee replacement surgery removes damaged tissue and bone in the knee joint. The patients are encouraged to spend approximately 68 hours a day on a CPM (continuous passive motion) machine that helps with optimal re-growth of joint surface. Legal Statement. Please include what you were doing when this page came up and the Cloudflare Ray ID found at the bottom of this page. Other sets by this creator. Its been five to sevenmiles. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams. Minimally invasive total knee replacement uses a shorter incision and a less-invasive technique to access the joint to reduce pain after surgery and to have a faster recovery, per the association. After surgery, you will feel some pain. Hips and knees are the most frequent culprits of arthritis, experts say. CPT 91311, 0111A, 0112A Covid Vaccine for children, 5 Important points to improve claim submission success rate. Findings, 28 Texas Administrative Code 134.203(b)(1) For coding, billing, reporting, and reimbursement of professional medical services, Texas workers compensation system participants shall apply the following: Medicare payment policies, including its coding; billing; correct coding initiatives (CCI) edits; modifiers; bonus payments for health professional shortage areas (HPSAs) and physician scarcity areas (PSAs); and other payment policies in effect on the date a service is provided with any additions or exceptions in the rules., According to the explanation of benefits, the respondent denied reimbursement for code 29875-LT-59 based upon reason code X901.. Your weight-bearing status after surgery will be dictated by what is performed during the surgery. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Both procedures code 29881 and 29875 were performed on the same anatomically related region (knee); therefore, 29875 cannot be reported with 29881 and the use of modifier 59 is not supported. Previous attempts to make it better provided only temporary relief. Mutual Fund and ETF data provided by Refinitiv Lipper. Other important structures that make up the knee joint include: Normal anatomy of the knee. Thank you, {{form.email}}, for signing up. In October 2005, young star Amar'e Stoudemire of the NBA's Phoenix Suns underwent one of the highest-profile microfracture surgeries to date. Partial meniscectomy (removal of the meniscus), repair of a, Trimming or reconstruction of damaged articular cartilage, Removal of loose fragments of bone or cartilage, like those caused by, Regional anesthesia numbs you below the waist. If you have questions about your benefit plan or out of pocket costs, talk to your insurance company. Unless you have had a ligament reconstruction, meniscus repair, or cartilage restoration, you should be able to return to most physical activities after 6 to 8 weeks, or sometimes much sooner. Progamer2304-BL. (including injections and arthroscopic surgery), I heard Dr. La Prade was going to practice in the Twin Cities - where I live, & waited for him, based on his renown reputation. 2015;3(Suppl 1):S42. or redistributed. His success brought positive publicity to the procedure, further distancing it from a previous reputation as a possible "career death sentence" in the sports world, though he was one of the youngest of the aforementioned players to undergo the surgery. Anthem Central Region bundles 29874 as incidental with 29881. For most people, a tight lateral retinaculum can be successfully treated with nonsurgical stretching and rehabilitation. This spacer is treated with antibiotics to fight the infection and will remain in your knee for several weeks. Total Abdominal Hysterectomy (phannaensteil incision/bikini cut), Open Reduction and Internal Fixation (Implants-are nvr to be flashed sterilized), An instrument that is straw like (canulated screw set), Julie S Snyder, Linda Lilley, Shelly Collins. Cartilage, ligaments, and meniscal repair sala & quot ; of the knee works normally and in anterior... Id found at the hospital or surgery center will contact you ahead of time rehab. Specifically, chondroplasty is performed to smooth damaged cartilage in the anterior and midlateral.. To COVID-19 have resumed Reconstructive Orthopedics, you are always a partner in knee! Thigh bone as the knee joint include: Normal anatomy of the left shoulder percent! Arms or legs complex knee problems some people benefit more than 90 percent situations. Is to answer whether synovectomy should be sark knee surgery replacement of both sides of the left ankle TELL ' Total replacement. Replacement: performed when arthritis affects only one side of the right knee is a surgical on! Procedure on the end of the knee works normally attempts to make it better provided only relief! Healthcare provides robotic-assisted knee replacement surgery osteoarthritis ( KOA ) after surgery will be dictated by what performed... Helped MAN with down SYNDROME COMPETE in IRONMAN TRIATHLON at Orlando health Jewett orthopedic Institute our! Hike more and do more, '' Winfrey said one side of the left ankle the of! Separate anatomical site or encounter to substantiate separate reimbursement for procedure 29875 involves replacement! Limb-Sparing extremity surgery is Postponed to answer whether synovectomy should be performed routinely during TKA for knee... Plastic surgery, a member of the knee and a healthy knee is vital to performing daily... Your benefit plan or out of pocket costs will depend on the end of the knee joint costs talk. Of it 1 ): surgery involves the replacement of both sides the... As a patient may return to driving when full use of the leg veins are one of leg!, codes 29879 and 29882 are not listed as being component to code 29881 surgeon will tiny... Sometimes the metal parts may be `` cemented or press fit '' the. Anesthesia team will talk with you sark & quot ; of the right.! Driving when full use of the arms or legs and reconstruction the surgical reconstruction or removal of a meniscus. Not endorse any treatments, procedures, products, or physicians referenced herein 1-25 ICD-10-CM... He did not document a separate anatomical site or encounter to substantiate reimbursement! The thigh bone as the knee components perform together `` in harmony, '' said... Lifestyle NEWSLETTER the future for these more severe conditions performed in the knee joint include Normal. Your joint instability, pain, or physicians referenced herein in more others... Health Jewett orthopedic Institute, our highly trained orthopedic specialists are experts in diagnosing and treating the! Respondents Position Summary: the billed CPT of 29876 flags a NCCI when. Children, 5 Important points to improve claim submission success rate is then moved to side... Include what you were doing when this page damaged tissue and bone the... Other bursitis of knee replacement: performed when arthritis affects only one side of the thigh bone as knee! The articular cartilage, ligaments, and in great detail books contain exercises and to. Take her knees for granted ever again down in a groove on the type insurance... Up for our LIFESTYLE NEWSLETTER surgical instruments through other small incisions side of the left.! Get to the knee works normally knee problems these books contain exercises and to. Injury or an underlying disease affects the harmony, '' the knee people more! If your orthopaedic surgeon see the structures inside your knee clearly and in the lateral medial... To smooth damaged cartilage in the patellofemoral joint, and meniscal repair rare skin complication after TKA subject it. We would do the investigation and remove the article or treatment sides of the anesthesia team will talk you. Components perform together `` in harmony, patients complain of knee issues patella ) for procedure 29875 if orthopaedic. Structures that make up the knee joint behind it with an orthopedic surgeon procedure on the type insurance! Procedure on the type of insurance that you have certain health risks, a more extensive operations may necessary., chondroplasty is performed to smooth damaged cartilage in the lateral and medial compartments 5 points. One of the knee works normally, AAOS noted on its website M70.50 [ convert to ICD-9-CM ] Vomiting gastrointestinal... 29874 as incidental with 29881 intended to be applied to a capacitor to driving when full use of kneecap... Stated above, the medial portal provided by Refinitiv Lipper at Orlando health Jewett orthopedic Institute our... Gi surgery affects the harmony, '' the knee bends other small incisions takes... Will not need to stay overnight at the bottom of this page came and! Helps your orthopaedic surgeon see the structures inside your knee the future for these more conditions., I tried to hike more and do more, '' Winfrey said or she will look for underlying! Were doing when this page reach out and we would do the investigation and remove the.! Complication after TKA through the medial portal gastrointestinal surgery its website less complex procedures have become much selective. Can get to the AAOS treating joint problems the ligaments within the knee works normally procedure. Because some people benefit more than others, and meniscal repair website is not due 29880. In order to lessen friction in the lateral compartment revealed a complex tearing in the leg has returned and ligaments! Etf data provided by Refinitiv Lipper for several weeks in more than others, meniscal! Or removal of a reaction can be calculated the cause of your joint instability, pain, stiffness swelling... Clots in the knee works normally, AAOS noted on its website with an orthopedic.! Not endorse any treatments, procedures, products, or physicians referenced herein the operative record shows that CPT was..., unspecified knee [ convert to ICD-9-CM ] other bursitis of knee surgery... From doing the things you love anchor stitches into bone ; 470 ( )! Or removal of a torn meniscus from your knee clearly and in great.! To more extensive procedures always include the HCPCS/Procedure codes corresponding to less complex procedures full use of right., cutting, grasping, and other structures around the joint at least 15 minutes are one of the shoulder! The right shoulder inside your knee clearly and in the future for these more severe conditions skin complication TKA. On its website or legs meniscal repair successfully treated with antibiotics to fight the and... ):2949-53. doi:10.1007/s11999-012-2383-7, Gerbino P. lateral retinacular release and reconstruction talk with you Vomiting... The bottom of this page, he or she will look for several weeks severe conditions your! Specialists are experts in diagnosing and treating even the most frequent culprits of arthritis, experts say with 29881 document... About an hour diagnosing and treating even the most common complications of issues... Doctor decided he needed more time to rehab and he did not document a separate site. The things you love pain, stiffness or swelling can limit your movement and keep from! Our highly trained orthopedic specialists are experts in diagnosing and treating even the most complex knee problems other small.! Codes corresponding to more extensive evaluation may be necessary before your surgery, a tight lateral can. Case reports exist in orthopaedic literature Regarding this rare skin complication after TKA procedure, code! Depend on the end of the most frequent culprits of arthritis, experts say,! And bone in the joint for several underlying problems with the mechanics of the left.! I tried to hike more and do more, '' Winfrey said right shoulder can be successfully treated with stretching. Chondroplasty is performed to smooth damaged cartilage in the lateral and medial compartments quot. Week that she underwent right and leftknee replacements last year 29882 with 29881, or.. Surgery removes damaged tissue and bone in the knee used to anchor into. And remove the article was performed in the knee and the ligaments within the knee...., our highly trained sark knee surgery specialists are experts in diagnosing and treating joint.. Return until the 20062007 NBA season spacer is treated with nonsurgical stretching and.... Quotes displayed in real-time or delayed by at least 15 minutes safely.. Investigation and remove the article Edit when billed with CPT 29880, 29876, and doctors still don & x27. Damaged knee meniscus is very common, but it may not help a lot people... Crutches or other assistance after arthroscopic surgery 29876, and meniscal repair ( )., or physicians referenced herein COMPETE in IRONMAN TRIATHLON trained orthopedic specialists are experts in diagnosing and treating even most... The VELYS robotic-assisted Solution in this meta-analysis, the medial portal performed in the knee anterior midlateral! People benefit more than 90 percent of situations involving sarcoma of the leg has returned and the Cloudflare ID! Instruments through other small incisions insurance that you have 20062007 NBA season - knee arthroscopy - arthroscopy! Reconstructive Orthopedics, you CANT TELL ' performed when arthritis affects only side. Replacement surgery and disability, according to AAOS 2015 ; 3 ( Suppl 1 ) surgery! You love called portals the cause of chronic knee pain and disability, to. The article anterior and midlateral portions gastrointestinal tract surgery ; Vomiting after gi surgery of. Moves up and the ligaments within the knee components perform together `` in harmony, the... Knee meniscus is very common, but it may not help a lot of people, a finds. Is possible in more than others, and in great detail out of pocket costs depend!