Download BlueCross BlueShield of Western New York

Provider Respiratory Inservice
Welcome
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Opening Remarks
We will cover:
• Definition of Asthma & COPD
• Evidence based guidelines for diagnosis,
evaluation, and management of asthma
• Evidence based guidelines for diagnosis,
evaluation, and management of adult with COPD
• Coding
• BC/BS services available to assist your practices
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What is Asthma?
• Obstructive lung disease with
characteristics of:
– Airway obstruction; reversible in most patients
– Chronic airway inflammation (eosinophils)
– Increased airway responsiveness
• Onset of symptoms can occur at any age
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Asthma
• 34 million people in the U.S. currently
diagnosed with asthma
• 7.1 million children are diagnosed with
asthma
• 1.3 million visits to hospital outpatient
departments with asthma as a primary
diagnosis
• Asthma costs exceed $30 billion/year
• Asthma in the U.S. is growing every year
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U.S Department of Health and Human Resources Center for CDC: 12/2012
What is COPD?
• A common, preventable, and treatable
disease:
– Characterized by persistent airflow limitation
• Usually progressive
– Associated with an enhanced chronic
inflammatory response in the airways and the
lung to noxious particles or gases.
– Exacerbations and comorbidities contribute to
the overall severity in individual patients.
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COPD
• 16 million U.S. adults have been diagnosed
with COPD
• 15 million or more U.S. adults have COPD
that have not been diagnosed
• 4th leading cause of death in the U.S.
• Annual direct & indirect COPD Medical
Costs $42.6 billion
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U.S Department of Health and Human Resources Center for CDC: 2007
Differential Diagnosis
Asthma
SUGGESTIVE FEATURES
SUGGESTIVE FEATURES
* Onset early in life (often childhood).
* Onset in mid-life.
* Symptoms vary from day to day.
* Symptoms slowly progressive.
* Symptoms at night/early morning.
* Long smoking history.
* Allergy, rhinitis, and/or eczema also
present.
* Dyspnea during exercise.
* Family history of asthma.
* Largely irreversible airflow limitation.
* Largely reversible airflow limitation.
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COPD
Asthma vs. COPD
• Spirometry is required pre- and postbronchodilator to help differentiate
between Asthma and COPD
– Asthma = Reversibility
– COPD = No/partial reversibility
• Chest Xray – to order or not?
• Vaccinate for flu and pneumonia
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Case Study
• 45 year old female presents to the office
with complaints of shortness of breath and
wheezing. She has a history of asthma.
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History – Questions to ask
• Symptoms (wheezing, dyspnea, cough)
• Timing and Frequency
• Triggers
– Work environment: dust, fumes, chemicals
– Home environment: heating, mold, pets, dust,
roaches, cigarette/cigar smoke
– Exercise
– Upper Respiratory Infections
• Medications – inhalers, steroids and other
medications
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• Smoking history
• Family history
Findings
•
•
•
•
Smoker – 1 ppd X 10 years, quit age 30
SOB and wheezing – daily
Uses albuterol inhaler 1x per day
Wakes at least 1 night per week with a
cough
• Becomes SOB with exercise
• Works at Chevy plant Monday – Friday
• 2 courses of oral systemic corticosteroids
last 6 months
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Spirometry
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Asthma Spirometry Results
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Asthma Spirometry Results
Pre
Bronchodilator
Predicted
Actual
Predicted %
Actual
Predicted %
FEV1 (L)
3.11
2.21
71
2.49
80
13%
FVC (L)
3.88
3.33
86
3.53
91
6%
83
66
FEV1/FVC %
15
%
Post
Bronchodilator Change
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Guidelines
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http://www.nhlbi.nih.gov/guidelines/asthma/asthma_qrg.pdf
Classifying Asthma Severity
• According to EPR-3 guidelines, the
member is classified as having moderate
persistent asthma
• Diagnosis = moderate persistent asthma
– Next - therapy
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Step approach
– medications
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Asthma Medications
Quick-Relief medication:
• SABA (Short-Acting Beta Agonists)
Controller medications:
•
•
•
•
•
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ICS (Inhaled Corticosteroids)
LABA (Long-Acting Beta Agonists)
LABA/ICS Combinations
LEUKOTRIENE MODIFIERS
Miscellaneous (theophylline, cromolyn)
Next Steps
Education:
• Review Medications
• Review inhaler technique + compliance at
each visit
• Reducing exposure to triggers
• Review asthma action plan each follow-up
visit
• Smoking cessation assistance
• Vaccinate for flu and pneumonia
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Asthma Action Plan
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Follow-up: 2-6 weeks after initial visit
• ACT test – patient completes
• Assess level of symptom control with
current medication regime
• Medication compliance and technique
• Step up or step down, according to signs
and symptoms
• Patient education
• Referral to pulmonologist or allergist, if
needed
• Review and update Asthma action plan
• Encourage compliance
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Asthma Control Test
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5
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4
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Case study follow-up
•
•
•
•
•
•
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ACT test – review
SOB 1X in 3 weeks
No nighttime awakening
No SOB while exercising
Use albuterol inhaler 1X in 3 weeks
Repeat spirometry showed FEV1 > 80%
predicted
• Next follow up appointment in 1-6 months
• Well controlled
• Consider step down if well controlled for
at least 3 months
Follow-up
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Case Study
• 45 year old female presents to the office
with complaints of shortness of breath and
wheezing.
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History – Questions to ask
• Symptoms (SOB, cough, wheezing,
phlegm production, color, amount)
• Timing and Frequency
• Smoking history
• Medications – inhalers, steroids, other
medications
• Family history
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Findings
•
•
•
•
Smoker 2ppd since age 20
Dyspnea and wheezing
Uses albuterol inhaler 1x per day
Experiences cough and some dyspnea with
exercise
• Productive cough with white sputum
• Works at Chevy plant Monday – Friday
• Has been treated with 2 courses of
Prednisone in the past 6 months
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Is this COPD?
Spirometry MUST be performed!
Within 180 days from initial diagnosis
• Pulse oximetry – to do or not?
• Chest Xray – to do or not?
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COPD Spirometry Results
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COPD Spirometry Results
Pre
Bronchodilator
Predicted
Actual
Predicted %
Actual
Predicted %
FEV1 (L)
3.11
1.87
60
1.94
62
4%
FVC (L)
3.88
3.1
80
3.15
81
2%
83
60
FEV1/FVC %
32
%
Post
Bronchodilator Change
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COPD Medications
•
•
•
•
•
•
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SABA (Short-Acting Beta Agonists)
ICS (Inhaled Corticosteroids)
LABA (Long-Acting Beta Agonists)
LABA/ICS Combinations
Anticholinergics
Miscellaneous (theophylline, roflumilast, combivent)
Medications for Asthma & COPD
• Pharmacy Formulary
Type of
Medication
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Commercial/
Child Health Plus/
Healthy New York
Medicaid/
Family Health Plus
Medicare
SABA
ProAir HFA
Proventil HFA
ProAir HFA
Ventolin HFA
ProAir HFA
Xopenex HFA
LABA
Foradil, Serevent
Diskus
Serevent Diskus
Arcapta, Foradil,
Perforomist, Severent
Diskus
ICS
Asmanex, Flovent
Diskus/HFA,
Pulmicort, QVAR
Alvesco, Flovent
Diskus HFA, Pulmicort
Flexhaler, QVAR
Alvesco, Asmanex,
Flovent Diskus/HFA, QVAR
LABA/ICS
combos
Advair, Symbicort
Advair, Symbicort
Advair, Dulera, Symbicort
Anticholinergics
Spiriva, Atrovent
Spiriva, Atrovent
Spiriva, Atrovent
Miscellaneous
Combivent,
montelukast,
zafirlukast
Combivent,
montelukast,
zafirlukast
Combivent, Daliresp,
montelukast, zafirlukast
* Included medications are tier 1 (generics) and tier 2 (brands) for commercial/HNY/CHP.
*Included medications are covered for Medicaid on generic or brand tier.
*Included medications are tier 2 (non-preferred generic) and tier 3 (preferred brand) for Medicare
Next Steps
• Review medications
• Review inhaler technique & compliance at
each visit
• Review care plan each follow up visit
• Smoking cessation assistance
• Vaccinate for flu and pneumonia
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Follow up
• Follow up Q 6 months or sooner if
hospitalized or in ED for COPD
• Review symptoms at each visit
• Review Medications
• Spirometry every year
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Asthma Codes
Asthma
Codes Identifying Asthma
Description
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ICD-9-CM Diagnosis
Extrinisic (allergic) asthma
493.0
Intrinsic (non-allergic) asthma
493.1
Asthma + COPD
493.2
Asthma unspecified
493.9
Status asthmaticus
Add "1" as fifth digit to 493.0 or 493.1 or 493.2 or 493.9
Asthma exacerbation
Add "2" as fifth digit to 493.0 or 493.1 or 493.2 or 493.9
Exercise induced asthma
493.81
Cough variant asthma
493.82
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COPD Codes
COPD
Codes Identifying COPD
Description
ICD-9-CM Diagnosis
Chronic bronchitis - simple (catarrhal, "smoker's cough)
491.0
Chronic bronchitis - mucopurulent
491.1
Emphysema
492.8
Chronic bronchitis + emhysema
491.20
COPD with acute exacerbation
491.21
COPD with acute bronchitis
491.22
COPD nonspecific
496
Note: chronic bronchitis involves a persistent cough with sputum production
for at least 3 months in at least 2 consecutive years
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Smoking Cessation Codes
Smoking Cessation
Description
CPT
for 3-10 minutes of counseling
99406
for over 10 minutes of counseling
99407
* If a modifier is used on the smoking cessation code, documentation must
support both of the criteria for the E&M code and the smoking cessation code.
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Pulse Oximetry & Spirometry Testing Codes
Pulse Oximetry
Description
Non-invasive ear or pulse oximetry for oxygen
saturation; single determination
Multiple determinations
CPT
94760
94761
Spirometry Testing
Description
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CPT
Spirometry
94010
Spirometry pre and post bronchodilator administration
94060
Flu and Pneumococcal Vaccine Codes
Flu Vaccine Codes
Description
Influenza virus, preservative free, intramuscular
administration 3 years of age and older
Influenza virus, intramuscular administration 3 years of
age and older
Influenza virus, nasal administration
CPT
90656
90658
90660
Adult Pneumococcal Vaccine
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Description
CPT
Adult pneumoccoccal vaccine (23-valent polysaccharide)
90732
Administration Codes
Admin Codes
Description
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CPT
IM administration 1st component through age 18 with
counseling
90460
Each additional component through age 18 with counseling
90461
Immunization administration all ages without counseling
90471
Immunization administration-each additional all ages without
counseling
90472
Immunization oral/nasal administration all ages without
counseling
90473
Immunization oral/nasal administration-additional all ages
without counseling
90474
How we can help you
• One on one health coaching with a
registered nurse available to assist our
BCBS members
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Educate about disease process
Medication management
Address gaps in care
Coordinate services
Reinforce treatment plan
How we can help you
• We also have a team of social workers,
dieticians and outreach workers
• Community classes: www.bcbswny.com
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Smoking cessation
Nutrition
Weight management
Exercise programs
Stress management
How to access DM/CM services
• Fax referral form to 716-887-7913
• Phone – call 1-877-878-8785, option 2
• Member self referral
online at www.bcbswny.com
DM = “Disease mangement”
CM = “Case management”
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Questions
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Thank You!