[5,6,7] Three anastomoses are created including the. Methods This retrospective study enrolled 422 consecutive patients who underwent PD from January 2019 to. 2016 (effective 10/1/2015): New code (first year of non-draft ICD-10-PCS)Pancreatic cancer is the fourth leading cause of cancer deaths, being responsible for 7% of all cancer-related deaths in both men and women. [1,2] A pancreaticoduodenectomy is most commonly performed for patients with adenocarcinoma in the head or neck of the pancreas. It is caused by either a benign or malignant mechanical obstruction or a motility disorder interfering with gastric emptying. The head of the pancreas lies in the duodenal C loop in front of the inferior vena cava (IVC) and the left renal vein (see the images below). 84 and 863. 81 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Complete tumor resection with negative margins (R0 resection) is a prerequisite for cure. Current Procedural Terminology (CPT) is still used for all outpatient. Once testing has confirmed a diagnosis of pancreatic cancer, the next step is determining the right code to describe the patient’s condition. 8 Thus, we identified 4775 PD. 7%) patients underwent radiotherapy and/or chemotherapy with 39 patients. 2018. Introduction. Radical Pancreaticoduodenectomy. 4% vs. This is likely in part due. . Persons with potential health hazards related to family and personal history and certain conditions influencing health status. ObjectiveIn this study, we retrieved the data available in the Surveillance, Epidemiology, and End Results database to identify the prognostic factors for patients with pancreatic head cancer who had undergone pancreaticoduodenectomy and developed a prediction model for clinical reference. Pancreatic pseudoaneurysms, though rather uncommon, are frequently accompanied by life-threatening complications, mainly rupture and bleeding. Methods: This retrospective study was conducted on 116 patients who underwent pancreaticoduodenectomy or a similar procedure and had no clinical evidence of. 7 MeSH D016577 Other codes: A pancreaticoduodenectomy, pancreatoduodenectomy,[1] Whipple procedure, or Kausch-Whipple procedure, is a major surgical operation involving the pancreas, duodenum, and other organs. 01. 411 [convert to ICD-9-CM] Acquired partial absence of pancreas. The patient undergoes neoadjuvant chemoradiation and a. 07 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. ICD-10-PCS 0FTG0ZZ is a specific/billable code that can be used to indicate a procedure. 3% (n=863) and occurred at a median of 3. This was the first year ICD-10-CM was implemented into the HIPAA code set. Although the first published case was described in 1994, it has been slow to gain popularity . [Google Scholar]1,4,10–12 Few studies have addressed the concept of QOL in patients surviving pancreaticoduodenectomy. D016577. 0 by an endocrinologist. This is the American ICD-10-CM version of Z90. The 2024 edition of ICD-10-CM K91. 31 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. DOI: 10. Lynt B. Use Additional. 41) Z90. Introduction. Adenocarcinoma / surgery*. XXXA became effective on October 1, 2023. 91–863. 0 became effective on October 1, 2023. 3 became effective on October 1, 2023. Multimodal therapy is now a cornerstone of the management of pancreatic ductal adenocarcinoma (PDAC). C22. The 2024 edition of ICD-10-CM K90. Location. Author: tranque. This is the American ICD-10-CM version of D33. Pancreaticoduodenectomy (PD) is the standard surgical treatment for pancreatic and periampullary tumors, which involves resection of the duodenum as well as with or without the distal stomach, the first portion of the jejunum, the pancreatic head, and common bile duct with the gallbladder (). 53 to ICD-10-PCS; 52. A vascular cartridge was used as well as seam guard, and I was. Distal pancreatectomy may be used for isolated. 001) and fewer nodes positive (N0, 49% vs 28%; P < 0. 1. XXXA may differ. Background: Several studies have reported lower perioperative mortality rates with pancreaticoduodenectomy at high-volume hospitals than at low-volume hospitals. Currently, the. Z48. We identified a subset of procedures, not including cholecystectomy, deemed to be anatomically and technically related to pancreaticoduodenectomy using ICD-9-CM codes. Symptoms: nausea bloatingAn intusst. 52. 52. [ edit on Wikidata] The Puestow procedure (also known as a Puestow-Gillesby procedure, or a lateral pancreaticojejunostomy) is a surgical technique used in the treatment of chronic pancreatitis. 041. Use Additional. This procedure is associated with significant. 1 became effective on October 1, 2023. of 14 /14. The ICD-10 Procedure Coding System (ICD-10-PCS) is a system of medical classification used for procedural codes. All patients ≥ 18-year old presenting with penetrating pancreatic and/or duodenal injuries were identified using the International Classification of Diseases version-9 (ICD-9) diagnosis codes: 863. The incidence of pancreatic ductal adenocarcinoma (PDAC) has been on the rise in recent years; however, its clinical diagnosis and treatment remain challenging. ICD-9-CM. ICD-10-PCS before its release in 1998. 86 to ICD-10-PCS. One patient with a high-grade malignant neoplasm died after 15. 7. 53, 52. 1016/j. 410 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Pancreaticoduodenectomy Intervention: Pancreaticoduodenectomy ICD-10 code: ICD-9 code: 52. Reiter's disease. 815 contain annotation back-references C25. 09 - other international versions of ICD-10 K83. 02) and 90-day (7. The aim of this meta-analysis was to evaluate whether robotic pancreaticoduodenectomy (PD) may provide better clinical and pathologic outcomes compared to its open counterpart. ijsu. Pancreaticoduodenectomy (i. Find a Doctor. PMCID: PMC4616697. Epidemiology. 21 in conjunction with the procedure code for pancreaticoduodenectomy (52. Currently, laparoscopic pancreatic resection (LPR) is extensively applied to treat benign and low-grade diseases related to the pancreas. (2019) 269:733–40. ijsu. 01. 2012 ICD-9-CM Procedure Code 52. 3 - other international versions of ICD-10 K74. Introduction. This. The purpose of this population-based study was to determine the change of glucose metabolism in patients undergoing pancreaticoduodenectomy (PD). 59 were considered pancreatic head resections. 2,5,11 Assuming that PD involves the. Radical pancreaticoduodenectomy ICD-9-CM Vol 3 Code 52. Columbia, MO. Sometimes coders do this with a 52 modifier on the open code, however the reimbursement is then reduced and most surgeons I have talked to about. Parent Code: Z90. 52. 0 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Conclusion: An ICD-10-PCS definition of pancreaticoduodenectomy using codes for (1) open or percutaneous endoscopic excision or resection of the pancreas and (2) similar codes for the duodenum, consistent with coding guidelines, has satisfactory test characteristics. Superior pancreaticoduodenal artery. Moreover, the learning curve for the traditional open PD is significant,. 0]) 7 and inclusion in the Registry for Catastrophic Illness Patient Database, a subpart of the NHIRD. The aim of this study is to identify risk factors for RTOR following pancreaticoduodenectomy (PD) for ductal adenocarcinoma. 4)” so you should also report: Z90. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. +1-410-502-7683 International. 49: Carcinoma in situ. Understanding the potential complications and recognizing them are imperative to ta. 3 may differ. Synonyms: h/o: major abdominal surgery, history of pancreatectomy , A pancreaticoduodenectomy, pancreatoduodenectomy, or Whipple, is a surgical procedure involving the pancreas, intestines, and other organs. Applicable To. In highly experienced hands, LPD is a safe and feasible procedure. There were no differences in 30-day. Twitter. On univariate analysis, hypertension, PpPD, operation time, intraoperative bleeding, packed red blood cell transfusion ≥500 mL, and clinically. Pancreaticoduodenectomy, so-called "Whipple operation," is a time-consuming and technically demanding complex operation. 855-695-4872 Outside of Maryland. Laparoscopic surgery reduces surgical morbidity in various operations, however laparoscopic pancreaticoduodenectomy (LPD) is a relatively new procedure which lacks a clear consensus regarding its benefits (10-14). A Whipple by any other name would take the same code (s) — and those names might include pancreaticoduodenectomy, pancreatoduodenectomy,. A retrospective review of PDs for pNET (1998–2014) at our institution was conducted. 0 months), and hepatic steatosis on CT images was evaluated. The procedure involves removal of the “head” (wide part) of the pancreas next to the first part of the small intestine (duodenum). The 2024 edition of ICD-10-CM Z90. Traditional techniques for performing pancreaticoduodenectomy have emphasized the importance of establishing a tumor-free plane between the SMPV confluence and the neck of the pancreas. The 2024 edition of ICD-10-CM Z85. 2013. Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department. This increase is in large part due to the decreasing perioperative mortality rate, which is down from historic highs of 25% to the 1. This is the American ICD-10-CM version of C25. CCS is based on the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS), a uniform and standardized coding system. We divided the pancreas. Neoadjuvant chemotherapy (NAT),. Among 4,255 patients who underwent a pancreaticoduodenectomy or distal pancreatectomy, with a median follow-up of 10. The study population is a consecutive sample of older (greater than or equal to 75 years) and younger (16 to 74 years) patients from California (January 1990 to December 1996; n = 3,113) and UCSF (January 1993 to November 2000; n = 218), who underwent radical pancreaticoduodenectomy, distal pancreatectomy, or total. A robotic lateral pancreaticogastrostomy is performed with the objective of decompressing the pancreatic ductal system. 1. Although surgical resection remains the only chance for long-term patient survival, the likelihood of initial resectability is no higher than 20%. The most common of these include delayed gastric emptying and pancreatic fistula, accounting for up to 30% of postoperative complications [1–7]. 2/7/9, or E34. MeSH. 1], and duodenal cancer [ICD-9 152. Free 2006-2011 ICD-9-CM Codes. 3 - other international versions of ICD-10 Z48. Codes used to report surgeries for tumor excision in people with pancreatic cancer include: Distal Pancreatectomy – During this surgery, the left side of the pancreas is removed. We identified patients undergoing pancreaticoduodenectomy using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), code 52. Complete surgical removal of the tumor remains the only chance for cure, however 80-90% of patients have disease that is surgically incurable at the time of clinical presentation (15). We sought to compare MIS and open PD for pancreatic cancer resection in terms of short-term, long-term, and oncologic outcomes using the win ratio, a novel. Median survival following resection was 17 months. Search Results. With the introduction of laparoscopic and robotic surgery, minimally invasive. Background: Resection margin status is an important prognostic factor in pancreatic cancer; however, the impact of positive resection margins in those who received neoadjuvant therapy remains unclear. 1007/s11605-019-04316-8. Hemorrhage can occur in the pseudocyst itself, via the ampulla of Vater, or by fistulation into nearby hollow organs. These three “unwritten rules” well represent surgeons’ reverence and fear for pancreatic surgery. The 2024 edition of ICD-10-CM K83. 3 In. Early Versus Late Oral Refeeding After Pancreaticoduodenectomy for Malignancy: a Comparative Belgian-French Study in Two Tertiary Centers. However, true ampullary cancers have a better. #2. 1 (Postprocedural hypoinsulinemia). Procedure: 1. Summary and recommendation: Patients should receive dedicated preoperative counseling, preferably with multimedia informational materials rather than only spoken information with or without an educational pamphlet. Pancreaticoduodenectomy, also referred to as the “Whipple” or “Kausch-Whipple” procedure, is the most common surgical procedure for the resection of tumors in the pancreatic head, uncinate process, and neck as well as lesions of the ampulla, extrahepatic bile duct, and duodenum []. B15. Pancreatic fistula remains one of the most harmful and troublesome complications after laparoscopic pancreaticoduodenectomy (LPD) [1,2,3]. · Pancreaticoduodenectomy in Florida:. This can translate into some serious long-term effects, including. 4. 527 ICD-9 ⇄ ICD-10 Crosswalk . Information about the “527” (ICD-9) code. XXXA describes the circumstance. 03) mortality rates in 2017 compared to 2010. We excluded patients who were pregnant or were categorized as American Society of Anesthesiologists class 5, total pancreatectomy procedures, or procedures categorized as ‘outpatient’ in the registry. Computed tomographic scans failed to detect nodal metastases that were present in 4 patients. How to resolve this issue is challenged. The Centers for Medicare and Medicaid Services (CMS) maintain the catalog in the U. 1 : K00-K95. 8 Transplant Of Pancreas; 52. Controversy remains regarding when the risk of surgical intervention outweighs its potential benefit, particularly for operations such as pancreaticoduodenectomy (PD), which is associated with increased postoperative. 410 became effective on. 89 became effective on October 1, 2023. Background. This concept has been applied for pancreatic surgery since the first published guidelines in 2012. 7) between Jan 1, 1992, and Dec 31, 1995 (except the 8% of Medicare patients enrolled in risk-bearing health maintenance organizations during this period). Procedure complexity and volume–outcome relationships have led to increased regionalization of pancreaticoduodenectomy (PD) for pancreas cancer. This is the American ICD-10-CM version of Z90. liver cirrhosis (ICD-9 571. The history of the pancreaticoduodenectomy extends from the late 19th century with its ominous prohibitive mortality to its current stage where mortality has been reduced to less than 2%. However, this maneuver does not reveal tumor invasion of the lateral wall of the superior mesenteric vein (SMV) until after gastric and pancreatic transection. Reconstruction was with:Pancreaticoduodenectomy for side-branch IPMNs can be performed safely. 1%, p = 0. Therefore, these three diagnoses were categorized as being. The spleen is removed because of shared blood vessels with the pancreas. (ICD-0-3. Ayman El Nakeeb, Mohamed El Sorogy, Helmy Ezzat, Rami Said, Mohamed El Dosoky, Mohamed Abd El Gawad, Ahmed M Elsabagh and Ehab El Hanafy, Predictors of long-term survival after pancreaticoduodenectomy for peri-ampullary adenocarcinoma: A retrospective study of 5-year survivors, Hepatobiliary & Pancreatic Diseases. Pancreaticoduodenectomy: laparoscopic versus open. The 2024 edition of ICD-10-CM K74. 0]) 7 and inclusion in the Registry for Catastrophic Illness Patient Database, a subpart of the NHIRD. 21, 863. The 2024 edition of ICD-10-CM B15. K90. NSQIP (2009-2012) was used. Pancreaticoduodenectomy; ICD-10 code: ICD-9 code: 52. W08. Z90. Traditionally, this procedure has been performed most usually by open approach, which results in a large and painful wound. 7 (radical pancreaticoduodenectomy). Background: It remains controversial whether the additional Braun enteroenterostomy (BEE) is necessary in decreasing delayed gastric emptying (DGE) following pancreaticoduodenectomy (PD). 89 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 52. The aim of this article is to compare a multicenter center risk of LPD in elderly and nonelderly patients. 7), or total pancreatectomy. Pancreaticoduodenectomy (PD) is one of the greatest challenges in gastrointestinal surgery, with mortality < 5% in high-volume centers, and even 50% of perioperative complications [ 1, 2 ]. One of the most common complications after PD is surgical site infection (SSI). 1016/j. 7 is a specific code and is valid to identify a procedure. The 2024 edition of ICD-10-CM K68. 7 (pancreaticoduodenectomy); 52. It is a subset of the International Statistical Classification of Diseases and Related Health Problems (ICD) 9-CM. 815 became effective on October 1, 2023. scepting end-to-end pancreaticojejunostomy was perfomled in 44 patients (67%). The clinical symptoms are weight loss, upper abdominal pain, postprandial vomiting, and nausea due to duodenal stenosis. With the improvements of surgical techniques,. 07 - other international versions of ICD-10 Z85. XXXA - other international versions of ICD-10 W08. As we hypothesized, cause of death between the early and late post-pancreaticoduodenectomy patients differs significantly. Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove cancerous tumours from the head of the pancreas. 80. Pancreaticoduodenectomy in Florida: do 20-year. 815 may differ. Chapter 4 - Queensland Health · Chapter 4 Pancreaticoduodenectomy. We would like to show you a description here but the site won’t allow us. [2] This activity reviews the procedure of pancreaticoduodenectomy, relevant surgical anatomy, technical details, contraindications, and complications. Other codes: A pancreaticoduodenectomy, Whipple procedure, or Kausch-Whipple procedure, is a major surgical operation involving the pancreas, duodenum, and other organs. 10. 52. 8%) in the PrPD group had DGE, showing a significant difference (p < 0. Use Additional. In all of the described techniques, the jejunal limb is brought to the supracolic compartment in a retro colic. PDAC is an aggressive and difficult malignancy to treat. Pancreatic exocrine insufficiency (PEI) may be caused or exacerbated by surgery and remains underdiagnosed and undertreated. Pancreaticoduodenectomy is a classic surgical procedure for the treatment of benign and malignant tumors around the head of the pancreas, the lower common bile duct, the duodenum, and the ampulla (). This is the American ICD-10-CM version of K74. 6% and increases to 16. Aug 20, 2012. 2 Almost half of all PDAAs are associated with celiac axis stenosis (CAS) 2 and median arcuate ligament (MAL) compression, which creates a “hooked” appearance that is characteristic of MAL syndrome (MALS), noted in 10% to 30% of such cases. The 2024 edition of ICD-10-CM Z48. Access to technologic advances often neglect the. 48145 Pancreatectomy, distal subtotal, with or without splenectomy; with pancreaticojejunostomy. This is the American ICD-10-CM version of B15. The derotation group had a significantly higher incidence of early, that is, before division of the drainage vein. Due to the shared blood supply of organs in the proximal gastrointestinal. In 10 patients, a pancreatogastrostomy was performed; all of the remaining patients underwent a pancreatojejunostomy. The 2024 edition of ICD-10-CM L92. This is the American ICD-10-CM version of B15. The lesions show papillary proliferation, cyst formation, and varying degrees of cellular atypia [ 1,2 ]. Methods: A literature search was performed in PubMed, Embase (Ovid), and the. In this single institution study, 30-d mortality after pancreaticoduodenectomy is 1. Introduction. This is the American ICD-10-CM version of E08 - other international versions of ICD-10 E08 may differ. 07 became effective on October 1, 2023. 1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 815 - other international versions of ICD-10 Z48. Surgeons and hospitals: new risk factors? Today many authors support the concept that among the most important factors affecting the rate of pancreatic anastomotic leak are the surgeon's and centre's experience 1,3,8,9,10,11,12,13,15,76. Treatment algorithms increasingly employ a multimodal strategy, which includes neoadjuvant and adjuvant therapies. Preoperative biliary stenting increased from 29. This is the American ICD-10-CM version of Z85. This is the American ICD-10-CM version of Z48. whereas an end-to-side pancreaticojejunostomy THE AMERICAN JOURNAL OF SURGERY" VOLUME 1614 OCTOBER 1994 295 ANASTOMOTIC LEAK AI~+I'ER PANCREATICODUOI)ENECTOMY/CULLEN ET At, TABLE I Indications for. The 2024 edition of ICD-10-CM Z90. Methods A total of 177 pancreatic head cancer patients who underwent. 520 - other international versions of ICD-10 Z85. A chronic systemic infection by a gram-positive. INTRODUCTION. 3 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 0001). Its treatment is via pancreaticoduodenectomy (Whipple's procedure). Nutrition after your pancreaticoduodenectomy (Whipple procedure) Page - 3 Possible nutrition problems Gastroparesis What To Do What is it? A condition where food moves through your stomach slower than normal and takes longer to digest. Indications included cystic lesions, IPMNs, and neuroendocrine pancreatic tumors. Knowledge regarding outcomes after PD comes from single-institutional series, which may be limited if a significant number of patients follow up at other hospitals. Other epilepsy, not intractable, without status epilepticus. Match case Limit results 1 per page. D010193. Among 4,255 patients who underwent a pancreaticoduodenectomy or distal pancreatectomy, with a median follow-up of 10. doi: 10. The completeness of resection resulting from pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma, while not part of the TNM staging system, has powerful prognostic significance for recurrence and survival. 7 MeSH D016577 Other codes: A pancreaticoduodenectomy, pancreatoduodenectomy,[1] Whipple procedure, or Kausch-Whipple procedure, is a major surgical operation involving the pancreas, duodenum, and other organs. Baumgart pancreaticojejunostomy is considered one of the safest anastomosis procedures, with low rates of pancreatic fistula. The uncinate process is an extension of the lower (inferior) half of the head toward the left; it is of varying size and is wedged between the superior mesenteric vessels (vein on the right, artery on the left) in. 92 Cannulation of pancreatic duct convert 52. Antineoplastic Combined Chemotherapy Protocols / therapeutic use. 18–22 The two most comprehensive QOL studies published to date are those of McLeod et al 18 and Melvin et al. Five patients were treated by pancreaticoduodenectomy, 4 for low-grade neuroendocrine tumors and 1 for high-grade neuroendocrine carcinoma. MethodsWe screened the data between 1973 and 2015. 2], PC [ICD-9 157. 7%, respectively. Specialty: Gastroenterology,. Whipple pancreaticoduodenectomy (WPD) is the standard surgery for periampullary cancers and cancers of the head of pancreas. The primary outcome was the development of postoperative P-DM after surgery. 41 - other international versions of ICD-10 Z90. Indications for su rgery included pancreatic head tumor (n = 18), ampullary carcinoma (n =8), bile duct carcinoma (n = 22), gallbladder carcinoma (n = 2), and trauma (n = 1). 2, C25. 49 may differ. Transverse colectomy EN bloc with complete mobilization of the splenic flexure. The overall postoperative mortality rate was 5. 1) and consultation with our gastrointestinal pathologist . Ninety-five patients who underwent PD at. 52. 0. 2020; 34. A procedure once associated with an. Approximately 75% of all pancreatic carcinomas occur within the head or neck of the pancreas, 15-20% occur in the body of the pancreas, and 5-10% occur in the tail. 1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. We investigated its effectiveness in prediction of major complications (LPPC) after. This was a retrospective cohort study using the AHRQ HCUP SID for California from 2009 to 2011 to identify patients undergoing pancreaticoduodenectomy (ICD-9-CM procedure codes: 52. 1016/j. Pancreaticoduodenectomy (PD) is the main therapy for resectable and borderline resectable pancreatic ductal adenocarcinoma (PDAC) []. This surgical procedure poses immense difficulties to the surgeons due to the complex as well as highly difficult intra-abdominal dissection and likewise the. 7% and 18. In comparison, a PPPD preserves the distal stomach, pylorus, and first portion of the duodenum. 9). Only a few reports have described surgical difficulties in patients with CTPV. Although surgical resection is a therapy implemented to treat pancreatic cancer, the rates of mortality remain high, and the 5-year survival rate is only 10–20% [2, 3]. The 2024 ICD-10-PCS codes are to be used for discharges occurring from October. 1 may differ. 1,3,5,7,8,9,10 The degree of glucose metabolism impairment after pancreatectomy is related to the extent of pancreatic parenchyma resection, underlying pancreatic disease, and duration of follow-up. Current mortality after PD performed at high volume centers is as low as 1–2 % due to improvements in operative technique and perioperative care. This is the American ICD-10-CM version of Z90. 86 Transplantation of cells of Islets of Langerhans, not otherwise specified convert 52. Context 2. 0: Malignant neoplasm of duodenum: C22. The following code(s) above S42. The procedure is one of the most complicated operations in hepatobiliary and pancreatic surgery, involving the removal of the pancreas, duodenum, and biliary tract and the reconstruction of the. A robotic lateral pancreaticogastrostomy is performed with the objective of decompressing the pancreatic ductal system. 2011. 041. The celiac artery and its branches; the stomach has been reflected superiorly and the peritoneum removed. The procedure includes a 30–40% distal gastrectomy known as the conventional pancreaticoduodenectomy (cPD). · ICD 10 code WHO description C25. MeSH. This complex procedure is associated with a high morbidity rate. 9, 23, 25. 4-11.