Provider Respiratory Inservice

Transcription

1 Provider Respiratory Inservice

2 2 Welcome

3 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 3

4 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 4

5 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

6 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. 6

7 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 4 th 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

8 Differential Diagnosis Asthma SUGGESTIVE FEATURES * Onset early in life (often childhood). * Symptoms vary from day to day. * Symptoms at night/early morning. * Allergy, rhinitis, and/or eczema also present. * Family history of asthma. COPD SUGGESTIVE FEATURES * Onset in mid-life. * Symptoms slowly progressive. * Long smoking history. * Dyspnea during exercise. * Largely irreversible airflow limitation. * Largely reversible airflow limitation. 8

9 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 9

10 Case Study 45 year old female presents to the office with complaints of shortness of breath and wheezing. She has a history of asthma. 10

11 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 11 Medications inhalers, steroids and other medications Smoking history Family history

12 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 12

13 13 Spirometry

14 14 Asthma Spirometry Results

15 Asthma Spirometry Results Pre Post Bronchodilator Bronchodilator Predicted Actual Predicted % Actual Predicted % % Change FEV1 (L) % FVC (L) % FEV1/FVC %

16 Guidelines 16

17 Classifying Asthma Severity According to EPR-3 guidelines, the member is classified as having moderate persistent asthma Diagnosis = moderate persistent asthma Next - therapy 17

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19 19 Step approach medications

20 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) 20

21 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 21

22 22 Asthma Action Plan

23 23 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

24 Asthma Control Test

25 25 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 months

26 26 Follow-up

27 Case Study 45 year old female presents to the office with complaints of shortness of breath and wheezing. 27

28 History Questions to ask Symptoms (SOB, cough, wheezing, phlegm production, color, amount) Timing and Frequency Smoking history Medications inhalers, steroids, other medications Family history 28

29 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 29

30 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? 30

31 31 COPD Spirometry Results

32 COPD Spirometry Results Pre Post Bronchodilator Bronchodilator Predicted Actual Predicted % Actual Predicted % % Change FEV1 (L) % FVC (L) % FEV1/FVC %

33 COPD Medications SABA (Short-Acting Beta Agonists) ICS (Inhaled Corticosteroids) LABA (Long-Acting Beta Agonists) LABA/ICS Combinations Anticholinergics Miscellaneous (theophylline, roflumilast, combivent) 33

34 Medications for Asthma & COPD Pharmacy Formulary Type of Medication Commercial/ Child Health Plus/ Healthy New York Medicaid/ Family Health Plus Medicare SABA ProAir HFA ProAir HFA ProAir HFA Proventil HFA Ventolin 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 34 * 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

35 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 35

36 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 36

37 Asthma Codes Asthma Codes Identifying Asthma Description ICD-9-CM Diagnosis Extrinisic (allergic) asthma Intrinsic (non-allergic) asthma Asthma + COPD Asthma unspecified Status asthmaticus Add "1" as fifth digit to or or or Asthma exacerbation Add "2" as fifth digit to or or or Exercise induced asthma Cough variant asthma

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39 COPD Codes COPD Codes Identifying COPD Description ICD-9-CM Diagnosis Chronic bronchitis - simple (catarrhal, "smoker's cough) Chronic bronchitis - mucopurulent Emphysema Chronic bronchitis + emhysema COPD with acute exacerbation COPD with acute bronchitis COPD nonspecific 496 Note: chronic bronchitis involves a persistent cough with sputum production for at least 3 months in at least 2 consecutive years 39

40 Smoking Cessation Codes Smoking Cessation Description CPT for 3-10 minutes of counseling for over 10 minutes of counseling * 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. 40

41 Pulse Oximetry & Spirometry Testing Codes Pulse Oximetry Description CPT Non-invasive ear or pulse oximetry for oxygen saturation; single determination Multiple determinations Spirometry Testing Description Spirometry Spirometry pre and post bronchodilator administration CPT 41

42 Flu and Pneumococcal Vaccine Codes Flu Vaccine Codes Description CPT 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 Adult Pneumococcal Vaccine Description Adult pneumoccoccal vaccine (23-valent polysaccharide) CPT 42

43 Administration Codes Admin Codes Description IM administration 1st component through age 18 with counseling CPT Each additional component through age 18 with counseling Immunization administration all ages without counseling Immunization administration-each additional all ages without counseling Immunization oral/nasal administration all ages without counseling Immunization oral/nasal administration-additional all ages without counseling

44 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 44

45 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 45

46 How to access DM/CM services Fax referral form to Phone call , option 2 Member self referral online at DM = Disease mangement CM = Case management 46

47 47 Questions

48 Thank You!