Provider Respiratory Inservice

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Provider Respiratory Inservice. Welcome. 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 - PowerPoint PPT Presentation

Transcript of Provider Respiratory Inservice

BlueCross BlueShield of Western New York

Provider Respiratory Inservice2Welcome Opening Remarks3We will cover:Definition of Asthma & COPDEvidence 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

34 What is Asthma?Obstructive lung disease with characteristics of:Airway obstruction; reversible in most patientsChronic airway inflammation (eosinophils)Increased airway responsivenessOnset of symptoms can occur at any age Asthma34 million people in the U.S. currently diagnosed with asthma7.1 million children are diagnosed with asthma1.3 million visits to hospital outpatient departments with asthma as a primary diagnosisAsthma costs exceed $30 billion/yearAsthma in the U.S. is growing every year5U.S Department of Health and Human Resources Center for CDC: 12/2012

56 What is COPD?A common, preventable, and treatable disease:Characterized by persistent airflow limitationUsually progressiveAssociated 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. COPD16 million U.S. adults have been diagnosed with COPD 15 million or more U.S. adults have COPD that have not been diagnosed4th leading cause of death in the U.S.Annual direct & indirect COPD Medical Costs $42.6 billion7U.S Department of Health and Human Resources Center for CDC: 2007

78 Differential Diagnosis

Asthma vs. COPDSpirometry is required pre- and post- bronchodilator to help differentiate between Asthma and COPDAsthma = ReversibilityCOPD = No/partial reversibilityChest Xray to order or not?Vaccinate for flu and pneumonia9 Case Study45 year old female presents to the office with complaints of shortness of breath and wheezing. She has a history of asthma.10 History Questions to askSymptoms (wheezing, dyspnea, cough)Timing and FrequencyTriggersWork environment: dust, fumes, chemicalsHome environment: heating, mold, pets, dust, roaches, cigarette/cigar smokeExerciseUpper Respiratory InfectionsMedications inhalers, steroids and other medicationsSmoking historyFamily history11 FindingsSmoker 1 ppd X 10 years, quit age 30SOB and wheezing dailyUses albuterol inhaler 1x per dayWakes at least 1 night per week with a coughBecomes SOB with exerciseWorks at Chevy plant Monday Friday 2 courses of oral systemic corticosteroids last 6 months12 Spirometry13

13 Asthma Spirometry Results14

1415 Asthma Spirometry Results

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Guidelineshttp://www.nhlbi.nih.gov/guidelines/asthma/asthma_qrg.pdfEach RED circle, will present itself and disappear on a per click basis ~mjh16 Classifying Asthma SeverityAccording to EPR-3 guidelines, the member is classified as having moderate persistent asthmaDiagnosis = moderate persistent asthmaNext - therapy171718

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Step approach medications Asthma MedicationsQuick-Relief medication:SABA (Short-Acting Beta Agonists)

Controller medications:ICS (Inhaled Corticosteroids)LABA (Long-Acting Beta Agonists)LABA/ICS CombinationsLEUKOTRIENE MODIFIERSMiscellaneous (theophylline, cromolyn)20 Next StepsEducation:Review MedicationsReview inhaler technique + compliance at each visitReducing exposure to triggersReview asthma action plan each follow-up visitSmoking cessation assistanceVaccinate for flu and pneumonia

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Asthma Action Plan22 Follow-up: 2-6 weeks after initial visit23ACT test patient completesAssess level of symptom control with current medication regimeMedication compliance and techniqueStep up or step down, according to signs and symptomsPatient educationReferral to pulmonologist or allergist, if neededReview and update Asthma action planEncourage compliance

Patient case study- s/s are better- symptoms less than 2 x week, has not woken up at night, no shortness of breath w activity, used short acting beta 1 x w in 3 weeks; spirometry performed and results show FEV1 is > 80% of the predicted. Review meds- no change at this time. Smoking cessation discussed- Member states she has called quit line.2324

Asthma Control Test4454421 Case study follow-upACT test review SOB 1X in 3 weeksNo nighttime awakeningNo SOB while exercisingUse albuterol inhaler 1X in 3 weeksRepeat spirometry showed FEV1 > 80% predictedNext follow up appointment in 1-6 monthsWell controlledConsider step down if well controlled for at least 3 months2526 Follow-up

Case Study45 year old female presents to the office with complaints of shortness of breath and wheezing.

27 History Questions to askSymptoms (SOB, cough, wheezing, phlegm production, color, amount)Timing and FrequencySmoking historyMedications inhalers, steroids, other medications Family history28 FindingsSmoker 2ppd since age 20Dyspnea and wheezingUses albuterol inhaler 1x per dayExperiences cough and some dyspnea with exerciseProductive cough with white sputumWorks at Chevy plant Monday Friday Has been treated with 2 courses of Prednisone in the past 6 months29 Is this COPD?Spirometry MUST be performed!Within 180 days from initial diagnosisPulse oximetry to do or not?Chest Xray to do or not?30Discuss if needs Chest Xray3031

COPD Spirometry Results3132 COPD Spirometry Results

COPD MedicationsSABA (Short-Acting Beta Agonists)ICS (Inhaled Corticosteroids)LABA (Long-Acting Beta Agonists)LABA/ICS CombinationsAnticholinergicsMiscellaneous (theophylline, roflumilast, combivent)

33 Medications for Asthma & COPDPharmacy Formulary34Type ofMedicationCommercial/Child Health Plus/Healthy New YorkMedicaid/Family Health PlusMedicareSABAProAir HFAProventil HFAProAir HFAVentolin HFAProAir HFAXopenex HFALABAForadil, Serevent DiskusSerevent DiskusArcapta, Foradil, Perforomist, Severent DiskusICSAsmanex, Flovent Diskus/HFA, Pulmicort, QVARAlvesco, Flovent Diskus HFA, Pulmicort Flexhaler, QVARAlvesco, Asmanex, Flovent Diskus/HFA, QVARLABA/ICS combosAdvair, SymbicortAdvair, SymbicortAdvair, Dulera, SymbicortAnticholinergicsSpiriva, AtroventSpiriva, AtroventSpiriva, AtroventMiscellaneousCombivent, montelukast, zafirlukastCombivent, montelukast, zafirlukastCombivent, 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 StepsReview medicationsReview inhaler technique & compliance at each visitReview care plan each follow up visitSmoking cessation assistanceVaccinate for flu and pneumonia

35 Follow upFollow up Q 6 months or sooner if hospitalized or in ED for COPDReview symptoms at each visitReview MedicationsSpirometry every year36Review HEDIS measures related to ED or In Pt stay / medications - 3637 Asthma Codes

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493.02MEOW!!!3839 COPD CodesNote: chronic bronchitis involves a persistent cough with sputum production for at least 3 months in at least 2 consecutive years

40 Smoking Cessation Codes

* 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. 41 Pulse Oximetry & Spirometry Testing Codes

42 Flu and Pneumococcal Vaccine Codes

43 Administration Codes

How we can help youOne on one health coaching with a registered nurse available to assist our BCBS membersEducate about disease processMedication managementAddress gaps in careCoordinate servicesReinforce treatment plan44 How we can help youWe also have a team of social workers, dieticians and outreach workersCommunity classes:Smoking cessationNutritionWeight managementExercise programsStress management45www.bcbswny.com How to access DM/CM servicesFax referral form to 716-887-7913

Phone call 1-877-878-8785, option 2

Member self referral online at

DM = Disease mangementCM = Case management46www.bcbswny.com47QuestionsThank You!