Provider Respiratory Inservice. 2 Welcome Opening Remarks 3 We will cover: Definition of Asthma &...

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Provider Respiratory Inservice

Transcript of Provider Respiratory Inservice. 2 Welcome Opening Remarks 3 We will cover: Definition of Asthma &...

Page 1: Provider Respiratory Inservice. 2 Welcome Opening Remarks 3 We will cover: Definition of Asthma & COPD Evidence based guidelines for diagnosis, evaluation,

Provider Respiratory Inservice

Page 2: Provider Respiratory Inservice. 2 Welcome Opening Remarks 3 We will cover: Definition of Asthma & COPD Evidence based guidelines for diagnosis, evaluation,

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Welcome

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Opening Remarks

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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

5 U.S Department of Health and Human Resources Center for CDC: 12/2012

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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

7 U.S Department of Health and Human Resources Center for CDC: 2007

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Differential Diagnosis

* Onset early in life (often childhood).

* Symptoms vary from day to day.

SUGGESTIVE FEATURES

* Onset in mid-life.

* Symptoms slowly progressive.

* Largely irreversible airflow limitation.

COPDSUGGESTIVE FEATURES

Asthma

* Symptoms at night/early morning.

* Allergy, rhinitis, and/or eczema also present.

* Family history of asthma.

* Largely reversible airflow limitation.

* Long smoking history.

* Dyspnea during exercise.

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Asthma vs. COPD

• Spirometry is required pre- and post- bronchodilator 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

• Smoking history• Family history

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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

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%

FEV1/FVC % 83 66 71

% Change

Pre Bronchodilator

Post Bronchodilator

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Guidelines

http://www.nhlbi.nih.gov/guidelines/asthma/asthma_qrg.pdf

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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:• ICS (Inhaled Corticosteroids)

• LABA (Long-Acting Beta Agonists)

• LABA/ICS Combinations• LEUKOTRIENE MODIFIERS• Miscellaneous (theophylline, cromolyn)

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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

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• 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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Case study follow-up• 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 months25

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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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Page 28: Provider Respiratory Inservice. 2 Welcome Opening Remarks 3 We will cover: Definition of Asthma & COPD Evidence based guidelines for diagnosis, evaluation,

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

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%

FEV1/FVC % 83 60 62

% Change

Pre Bronchodilator

Post Bronchodilator

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COPD Medications

• SABA (Short-Acting Beta Agonists)

• ICS (Inhaled Corticosteroids)

• LABA (Long-Acting Beta Agonists)

• LABA/ICS Combinations• Anticholinergics• Miscellaneous (theophylline, roflumilast, combivent)

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Medications for Asthma & COPD• Pharmacy Formulary

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Type ofMedication

Commercial/Child Health Plus/Healthy New York

Medicaid/Family Health Plus Medicare

SABA ProAir HFAProventil HFA

ProAir HFAVentolin HFA

ProAir HFAXopenex 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

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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

Description 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

Codes Identifying Asthma

Asthma

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493.02

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COPD Codes

Note: chronic bronchitis involves a persistent cough with sputum production for at least 3 months in at least 2 consecutive years

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

COPDCodes Identifying COPD

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Smoking Cessation Codes

Description CPT

for 3-10 minutes of counseling 99406

for over 10 minutes of counseling 99407

Smoking Cessation

* 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

Description CPTNon-invasive ear or pulse oximetry for oxygen saturation; single determination

94760

Multiple determinations 94761

Description CPT

Spirometry 94010

Spirometry pre and post bronchodilator administration 94060

Spirometry Testing

Pulse Oximetry

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Flu and Pneumococcal Vaccine Codes

Description CPTInfluenza virus, preservative free, intramuscular administration 3 years of age and older

90656

Influenza virus, intramuscular administration 3 years of age and older

90658

Influenza virus, nasal administration 90660

Description CPT

Adult pneumoccoccal vaccine (23-valent polysaccharide) 90732

Flu Vaccine Codes

Adult Pneumococcal Vaccine

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Administration Codes

Description CPTIM 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

Admin Codes

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How we can help you

• One on one health coaching with a registered nurse available to assist our BCBS members– Educate about disease process– Medication management– Address gaps in care– Coordinate services– Reinforce treatment plan

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How we can help you

• We also have a team of social workers, dieticians and outreach workers

• Community classes:– Smoking cessation– Nutrition– Weight management– Exercise programs– Stress management

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www.bcbswny.com

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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

DM = “Disease mangement”CM = “Case management”

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www.bcbswny.com

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Questions

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Thank You!