Provider Respiratory Inservice

1. Provider Respiratory Inservice

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

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

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 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.

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 • 4thleading cause of death in the U.S. • Annual direct & indirect COPD Medical Costs $42.6 billion U.S Department of Health and Human Resources Center for CDC: 2007

8. Differential Diagnosis

9. 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

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.

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 • 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

13. Spirometry

14. Asthma Spirometry Results

15. Asthma Spirometry Results

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

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

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)

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

22. Asthma Action Plan

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 4 4 5 4 4 21

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. Follow-up

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

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

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

30. Is this COPD? SpirometryMUST be performed! Within 180 days from initial diagnosis • Pulse oximetry – to do or not? • Chest Xray – to do or not?

31. COPD Spirometry Results

32. COPD Spirometry Results

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

34. Medications for Asthma & COPD • Pharmacy Formulary * 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

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

37. Asthma Codes

38. 493.02

39. COPD Codes Note: 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

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

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 www.bcbswny.com

46. 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” www.bcbswny.com

47. Questions

48. Thank You!