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 BC/BS services available to assist your practices

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

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

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.

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

Differential Diagnosis

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

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

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

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

Spirometry

Asthma Spirometry Results

Asthma Spirometry Results

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

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

Step approach – medications

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)

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

Asthma Action Plan

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.

Asthma Control Test 4 4 5 4 4 21

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

Follow-up

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

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

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

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

COPD Spirometry Results

COPD Spirometry Results

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

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

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

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 -

Asthma Codes

493.02 MEOW!!!

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

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.

Pulse Oximetry & Spirometry Testing Codes

Flu and Pneumococcal Vaccine Codes

Administration Codes

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

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

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

Questions

Thank You!