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
4th leading 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
Each RED circle, will present itself and disappear on a per click basis ~mjh

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. Quick-Relief medication:
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
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.

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. Spirometry MUST be performed!
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?
Discuss if needs Chest Xray

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
Type of
Medication
Commercial/
Child Health Plus/
Healthy New York
Medicaid/
Family Health Plus
Medicare
SABA
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, Dulera, Symbicort
Anticholinergics
Spiriva, Atrovent
Miscellaneous
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

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
Review HEDIS measures related to ED or In Pt stay / medications -

37. Asthma Codes

38. 493.02
MEOW!!!

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

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”

47. Questions

48. Thank You!