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Implementing High QualityImplementing High Quality
Telephone Care in PediatricTelephone Care in Pediatric
PracticePract...
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Implementing High Quality TelephoneImplementing High Quality Telephone
Care in Pediatric Practice:Care in Pediatric Prac...
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
Care in Pediatric Practice :Care in Pediatric Pra...
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
Care in Pediatric Practice:Care in Pediatric Pra...
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
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Implementing High Quality TelephoneImplementing High Quality Telephone
Care in Pediatric Practice:Care in Pediatric Pra...
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Implementing High Quality TelephoneImplementing High Quality Telephone
Care in Pediatric Practice :Care in Pediatric Pr...
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Implementing High Quality TelephoneImplementing High Quality Telephone
Care in Pediatric Practice :Care in Pediatric Pr...
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Using Telephone Care for ChildrenUsing Telephone Care for Children
with a Chronic Disease: Asthmawith a Chronic Disea...
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Care Plan Oversight: DefinitionCare Plan Oversight: Definition
 Individual physician supervision of a patientIndividua...
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Types of CallsTypes of Calls
 Call involves:Call involves:
• Services that involve a new treatmentServices that involv...
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CPO for Chronic ConditionsCPO for Chronic Conditions
 Previously diagnosedPreviously diagnosed
 Initial plan of care ...
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CPO for Chronic Conditions:CPO for Chronic Conditions:
AsthmaAsthma
 Why is asthma a good model?Why is asthma a good m...
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CPO for Asthma: WhenCPO for Asthma: When
 Monitoring controlMonitoring control
 Loss of controlLoss of control
• Medi...
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CPO for Asthma: HowCPO for Asthma: How
 Use existing national guidelines andUse existing national guidelines and
algor...
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Asthma ControlAsthma Control
 The degree to which the manifestations ofThe degree to which the manifestations of
asthm...
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Content of Asthma CPOContent of Asthma CPO
 Expectations about asthmaExpectations about asthma
• “Your asthma can be c...
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Content of Asthma CPOContent of Asthma CPO
 Patient’s treatment preferencesPatient’s treatment preferences
• ”What pro...
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Content of Asthma CPOContent of Asthma CPO
 Teach or review all educational strategies:Teach or review all educational...
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Control: ImpairmentControl: Impairment
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Long term control medication Dose Duration Problems
ICS (daily dose)
LTRA
LABA
Other
Significant exacerbations Number D...
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Assessment and Plan
Assessment
Control poor  Inadequate Optimal
Side Effects Prohibitive Acceptable Minimal
Crite...
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Goals Met In
Progress
Notes
Decrease nocturnal symptoms
Decrease daytime symptoms
Decrease albuterol use
Improve exerci...
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Coding
Time Call Ended
Call Duration  <5min  5-10 min  11-20 min  >20 min
CPT Code:
Telephone Care  99441 (5-10 mi...
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Telephone Services 2008Telephone Services 2008
 Telephone evaluation and managementTelephone evaluation and management...
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Acute Asthma CareAcute Asthma Care
 AssessAssess: When is it mild?: When is it mild?
• Dyspnea only with activityDyspn...
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Not for infants
Not for those with severe, brittle
disease or at risk of death from
asthma
Properly trained and equippe...
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CPT Code:  99441 (5-10 min) 99442 (11-20 min) 99443 (>20
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Asthma Action Plan
The colors of the traffic light
will help you use your asthma
medicines
Date of Discharge Next Docto...
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SummarySummary
 Use CPO to monitor treatment ofUse CPO to monitor treatment of
chronic asthma (chronic asthma (99339, ...
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Implementing High Quality Telephone Care in Pediatric Practice

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  • patient not under the care of a home health agency, hospice, or nursing facility
  • Transcript of "Implementing High Quality Telephone Care in Pediatric Practice"

    1. 1. 11 Implementing High QualityImplementing High Quality Telephone Care in PediatricTelephone Care in Pediatric PracticePractice Randall Sterkel MDRandall Sterkel MD Medical DirectorMedical Director Call CenterCall Center St. Louis Children’s HospitalSt. Louis Children’s Hospital QuIIN QI Conference Call Series for Network Members July 24, 2009
    2. 2. 2 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Telephone Care is CommonTelephone Care is Common  2,000-3,000 calls/yr/MD2,000-3,000 calls/yr/MD  10-15 clinical calls/day/MD10-15 clinical calls/day/MD  20% in-office care20% in-office care  80% after-hours care80% after-hours care  27% of decisions to see a subspecialist27% of decisions to see a subspecialist made over the phonemade over the phone  Significant chronic care diseaseSignificant chronic care disease management done over the phonemanagement done over the phone
    3. 3. 3 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice :Care in Pediatric Practice : Telephone Care is IncreasingTelephone Care is Increasing  EasyEasy  ConvenientConvenient  SafeSafe  Dual-working familiesDual-working families  Doctors pushed to see more patientsDoctors pushed to see more patients  Cost-efficientCost-efficient
    4. 4. 4 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice :Care in Pediatric Practice : Telephone Care is SafeTelephone Care is Safe  Goal of study to assess:Goal of study to assess: (1) frequency of death or potential under-referral(1) frequency of death or potential under-referral associated with hospitalization within 24 hours after aassociated with hospitalization within 24 hours after a call, andcall, and (2) factors associated with potential under-referral.(2) factors associated with potential under-referral.  Results:Results: • No deaths occurred within < 1 week after theNo deaths occurred within < 1 week after the after-hours calls.after-hours calls. • Rate of potential under-referral withRate of potential under-referral with subsequent hospitalization was 0.2%, or 1subsequent hospitalization was 0.2%, or 1 case per 599 triaged callscase per 599 triaged calls Source: Pediatrics. 118(2):457-63, 2006Source: Pediatrics. 118(2):457-63, 2006
    5. 5. 5 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice :Care in Pediatric Practice : Telephone Care is Cost-EffectiveTelephone Care is Cost-Effective  The provision of after-hoursThe provision of after-hours telephone care results in an averagetelephone care results in an average savings for payers of $56 per callsavings for payers of $56 per call • Pediatrics 2007; 119: e305-e313Pediatrics 2007; 119: e305-e313
    6. 6. 6 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Quality Improvement in Telephone CareQuality Improvement in Telephone Care  Quality of Care  The degree to which health care services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge.  IOM 1990
    7. 7. 7 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Quality Improvement in Telephone CareQuality Improvement in Telephone Care  Quality Improvement  A key component of quality improvement science is addressing unwarranted variation in care and outcomes which are often due to inconsistent adherence by health care providers to evidence-based approaches to care, reflecting problems in the system for health care delivery  IOM 2001
    8. 8. 8 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Telephone Care is Evidence-BasedTelephone Care is Evidence-Based  Pediatric Telephone ProtocolsPediatric Telephone Protocols  Office Version and After-Hours VersionOffice Version and After-Hours Version  Barton Schmitt MD FAAPBarton Schmitt MD FAAP
    9. 9. 9 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Telephone Care DocumentationTelephone Care Documentation  Purpose of DocumentationPurpose of Documentation • Continuity of careContinuity of care • Meet requirements of E/M visit or care planMeet requirements of E/M visit or care plan oversight for coding/billingoversight for coding/billing  Content of DocumentationContent of Documentation • Date and time of call, patient’s name, date ofDate and time of call, patient’s name, date of birth, reason for call, relevant history andbirth, reason for call, relevant history and evaluation, assessment, plan, disposition, totalevaluation, assessment, plan, disposition, total encounter timeencounter time  Location of DocumentationLocation of Documentation • Chart and/or Telephone Log – must beChart and/or Telephone Log – must be retrievableretrievable
    10. 10. 10 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Services Appropriate for Telephone CareServices Appropriate for Telephone Care  TriageTriage  Acute Illness CareAcute Illness Care  Chronic Disease ManagementChronic Disease Management  Medication AdjustmentsMedication Adjustments  Test Result InterpretationTest Result Interpretation  CounselingCounseling  Patient EducationPatient Education
    11. 11. 11 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Care ExamplesCare Examples  Acute Illness Care:Acute Illness Care:  Conjunctivitis:Conjunctivitis: • Purulent eye d/c +/- redness -> exclusion from school/daycarePurulent eye d/c +/- redness -> exclusion from school/daycare (Mo Dept Health)(Mo Dept Health) • >70% purulent d/c due to bacterial conjunctivitis (J Peds,>70% purulent d/c due to bacterial conjunctivitis (J Peds, 1993)1993) • Child may return to school/daycare after starting eye dropsChild may return to school/daycare after starting eye drops (AAP, 2005)(AAP, 2005) • Careful Telephone treatment:Careful Telephone treatment: • Speeds child’s recovery and return to school/daycareSpeeds child’s recovery and return to school/daycare • Saves parent copay and possible missed workSaves parent copay and possible missed work • Saves insurer balance of office visitSaves insurer balance of office visit
    12. 12. 12 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Care ExamplesCare Examples  Chronic Disease Management:Chronic Disease Management:  ADD:ADD:  PEDIATRICS Vol. 108 No. 4 October 2001, pp. 1033-1044  AMERICAN ACADEMY OF PEDIATRICS: Clinical Practice Guideline: Treatment of the School- Aged Child With Attention-Deficit/Hyperactivity Disorder  Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement  “The clinician should periodically provide a systematic follow-up for the child being treated for ADHD. Plans for follow-up should include obtaining information through office visits and telephone calls.”
    13. 13. 13 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Care ExamplesCare Examples  Chronic Disease Management:Chronic Disease Management:  ADDADD  HEDIS 2009 Measure  Follow-up care for Children Prescribed ADHD Medication  An initiation phase visit in the first 30 days  At least two follow-up visits from 31-300 days post-initiation.  One of the three visits may be a telephone visit with a practitioner  CPT Codes 99441-2 added to identify telephone visits
    14. 14. 14 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Care ExamplesCare Examples  Chronic Disease Management:Chronic Disease Management:  ADDADD  ADD Telephone Care Visit Form
    15. 15. 15 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Care ExamplesCare Examples  Chronic Disease Management:Chronic Disease Management:  Depression/AnxietyDepression/Anxiety  ConstipationConstipation  Atopic DermatitisAtopic Dermatitis  AsthmaAsthma
    16. 16. 16 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Physician Care CodesPhysician Care Codes  99441 5-10 minutes of medical discussion99441 5-10 minutes of medical discussion RVU:RVU: .36.36  9944299442 11-20 minutes of medical discussion11-20 minutes of medical discussion RVU:RVU: .66.66  9944399443 >20 minutes of medical discussion>20 minutes of medical discussion RVU:RVU: .98.98
    17. 17. 17 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Nonphysician Care CodesNonphysician Care Codes  9896698966 5-10 minutes of medical discussion5-10 minutes of medical discussion  9896798967 11-20 minutes of medical discussion11-20 minutes of medical discussion  9896898968 >20 minutes of medical discussion>20 minutes of medical discussion • Same RVUs as MD-provided careSame RVUs as MD-provided care
    18. 18. 18 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Telephone Coding RulesTelephone Coding Rules  Telephone services are non-face-to-faceTelephone services are non-face-to-face evaluation and management (E/M) servicesevaluation and management (E/M) services provided using the telephone.provided using the telephone.  These codes are used to report episodes ofThese codes are used to report episodes of care by the physician (or RN) initiated by ancare by the physician (or RN) initiated by an established patientestablished patient or guardian of anor guardian of an established patient.established patient.  If the telephone service ends with a decisionIf the telephone service ends with a decision to see the patient within 24 hours or nextto see the patient within 24 hours or next available urgent visit appointment, the code isavailable urgent visit appointment, the code is not reported; rather the encounter isnot reported; rather the encounter is considered part of the preservice work of theconsidered part of the preservice work of the subsequent E/M service, procedure, and visit.subsequent E/M service, procedure, and visit.
    19. 19. 19 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Telephone Coding RulesTelephone Coding Rules  Likewise if the telephone call refers toLikewise if the telephone call refers to an E/M service performed and reportedan E/M service performed and reported by the physician within theby the physician within the previous 7previous 7 daysdays (either physician requested or(either physician requested or unsolicited patient follow-up) or withinunsolicited patient follow-up) or within the postoperative period of thethe postoperative period of the previously completed procedure, thenpreviously completed procedure, then the service(s) are considered part ofthe service(s) are considered part of that previous E/M service or procedure.that previous E/M service or procedure.  Do notDo not report 99441-99443 if reportingreport 99441-99443 if reporting 99441-99443 performed in the previous99441-99443 performed in the previous 7 days.7 days.
    20. 20. 20 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Care Plan Oversight Codes - Home SettingCare Plan Oversight Codes - Home Setting  Care Plan Oversight –Care Plan Oversight – patientpatient notnot under the care ofunder the care of a home health agency, hospice, or nursing facilitya home health agency, hospice, or nursing facility  Individual physician supervision of a patient inIndividual physician supervision of a patient in homehome…… (or other location)…(or other location)… requiring complex andrequiring complex and multidisciplinary care modalities involving regularmultidisciplinary care modalities involving regular physician development and/or revision of carephysician development and/or revision of care plans…communicationplans…communication (including(including telephone callstelephone calls)) for purposes of assessment or care decisions withfor purposes of assessment or care decisions with health care professional(s), family member(s)…health care professional(s), family member(s)… involved in the patient’s care… includinginvolved in the patient’s care… including adjustment of medical therapy,adjustment of medical therapy, within a calendarwithin a calendar monthmonth;;  9933999339 - 15-29 minutes- 15-29 minutes  9934099340 - >30 minutes- >30 minutes
    21. 21. 21 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice:Care in Pediatric Practice: Care Plan Oversight ImplementationCare Plan Oversight Implementation Develop a Tracking System-Develop a Tracking System-  Document all CPO activities in chart basedDocument all CPO activities in chart based on timeon time  Maintain a list of patients with CPO activityMaintain a list of patients with CPO activity  Pull Charts and ‘tally” all minutes at the endPull Charts and ‘tally” all minutes at the end of a calendar monthof a calendar month  Educate families about billingEducate families about billing
    22. 22. 22 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice :Care in Pediatric Practice : Payment for Telephone carePayment for Telephone care How Do You Get Started?How Do You Get Started? AAP Payment for Telephone Care ToolkitAAP Payment for Telephone Care Toolkit  Useful tools for implementationUseful tools for implementation  Provides a handy Timeline to ‘GoingProvides a handy Timeline to ‘Going Live”Live”  FreeFree download to AAP members ondownload to AAP members on Practice Management Online websitePractice Management Online website
    23. 23. 23 Implementing High Quality TelephoneImplementing High Quality Telephone Care in Pediatric Practice :Care in Pediatric Practice : Reasons Supporting National Trend forReasons Supporting National Trend for Telephone CareTelephone Care  Equivalent healthcare outcomes at lower costsEquivalent healthcare outcomes at lower costs  Affordable to payers and patientsAffordable to payers and patients  Widespread adoption of medical home model and relianceWidespread adoption of medical home model and reliance upon PCPupon PCP  Relieving pressures on overcrowded, understaffed hospitalRelieving pressures on overcrowded, understaffed hospital EDs for nonurgent careEDs for nonurgent care  Expanded practice options and paid accessibility forExpanded practice options and paid accessibility for physiciansphysicians  Patient-centered care (giving consumers flexibility andPatient-centered care (giving consumers flexibility and options when the choice is safe, reasonable, andoptions when the choice is safe, reasonable, and appropriate)appropriate)   Source: A Model for Telephone Medical Consults Guidelines for Decision-Makers, April 2008, TommySource: A Model for Telephone Medical Consults Guidelines for Decision-Makers, April 2008, Tommy G. Thompson et alG. Thompson et al
    24. 24. 2424 Using Telephone Care for ChildrenUsing Telephone Care for Children with a Chronic Disease: Asthmawith a Chronic Disease: Asthma Carolyn M. Kercsmar, MDCarolyn M. Kercsmar, MD Cincinnati Children’s HospitalCincinnati Children’s Hospital Medical CenterMedical Center QuIIN QI Conference Call Series for Network Members July 24, 2009
    25. 25. 25 Care Plan Oversight: DefinitionCare Plan Oversight: Definition  Individual physician supervision of a patientIndividual physician supervision of a patient in homein home • PatientPatient notnot under the care of a home healthunder the care of a home health agency, hospice, or nursing facilityagency, hospice, or nursing facility  Requiring complex and multidisciplinaryRequiring complex and multidisciplinary care modalities involving regular physiciancare modalities involving regular physician development and/or revision of care plans…development and/or revision of care plans… communication (including telephone calls)communication (including telephone calls) • for purposes offor purposes of assessmentassessment, or, or • care decisionscare decisions with health care professional(s),with health care professional(s), family member(s)…involved in the patient’s carefamily member(s)…involved in the patient’s care • adjustment of medical therapyadjustment of medical therapy,,  within a calendar monthwithin a calendar month  99339 (15-29 minutes) 99340 – (>3099339 (15-29 minutes) 99340 – (>30 minutes)minutes)
    26. 26. 26 Types of CallsTypes of Calls  Call involves:Call involves: • Services that involve a new treatmentServices that involve a new treatment • Chronic medication managementChronic medication management • Chronic disease flare managementChronic disease flare management • Reporting lab results that necessitate a managementReporting lab results that necessitate a management change or referralchange or referral • Extended behavioral counselingExtended behavioral counseling • Follow-up calls to an office visit,Follow-up calls to an office visit, butbut……  Timing of call in relation to office visitTiming of call in relation to office visit • Does not pertain to a recent or scheduled office visitDoes not pertain to a recent or scheduled office visit • Follow-up call in place of an office visitFollow-up call in place of an office visit  > 7 days since previous office visit for same condition> 7 days since previous office visit for same condition • Prevents an office visitPrevents an office visit
    27. 27. 27 CPO for Chronic ConditionsCPO for Chronic Conditions  Previously diagnosedPreviously diagnosed  Initial plan of care establishedInitial plan of care established  Stepwise care plan and treatmentStepwise care plan and treatment adjustments requiredadjustments required  Algorithms and/or monitoring toolsAlgorithms and/or monitoring tools availableavailable  Examples:Examples: • ADHDADHD • Constipation/encopresisConstipation/encopresis • AsthmaAsthma
    28. 28. 28 CPO for Chronic Conditions:CPO for Chronic Conditions: AsthmaAsthma  Why is asthma a good model?Why is asthma a good model? • Substantial morbiditySubstantial morbidity • ““Micromanagement” required for optimalMicromanagement” required for optimal controlcontrol • Complex treatment regimensComplex treatment regimens • Co-morbid conditions affect treatmentCo-morbid conditions affect treatment and outcomesand outcomes • Assessment tools and treatmentAssessment tools and treatment algorithms availablealgorithms available • Guided self-management is effectiveGuided self-management is effective
    29. 29. 29 CPO for Asthma: WhenCPO for Asthma: When  Monitoring controlMonitoring control  Loss of controlLoss of control • Medication step-upMedication step-up  Gain of controlGain of control • Medication step downMedication step down  Revision of treatment planRevision of treatment plan  Monitoring and assessing adherenceMonitoring and assessing adherence  Promoting self-managementPromoting self-management  Treatment of mild exacerbationsTreatment of mild exacerbations
    30. 30. 30 CPO for Asthma: HowCPO for Asthma: How  Use existing national guidelines andUse existing national guidelines and algorithmsalgorithms  Systematic data collection andSystematic data collection and actionsactions  Clear goals for the management planClear goals for the management plan
    31. 31. 31 Asthma ControlAsthma Control  The degree to which the manifestations ofThe degree to which the manifestations of asthma (symptoms, functionalasthma (symptoms, functional impairments, and risks of untowardimpairments, and risks of untoward events) are minimized and the goals ofevents) are minimized and the goals of therapy are met.therapy are met. • ImpairmentImpairment • RiskRisk • ResponsivenessResponsiveness  Severity:Severity: intrinsic intensity of diseaseintrinsic intensity of disease NAEPP Expert Panel Report 3, 2007
    32. 32. 32
    33. 33. 33 Content of Asthma CPOContent of Asthma CPO  Expectations about asthmaExpectations about asthma • “Your asthma can be controlled”  Asthma ControlAsthma Control • Minimize daytime, nighttime symptoms  Patient’s goals of treatmentPatient’s goals of treatment • Maximize activity  MedicationsMedications • “What medications are you taking?”  Environmental ControlEnvironmental Control • “Have you noticed anything at home or school that makes your asthma worse?” EPR3, 2007
    34. 34. 34 Content of Asthma CPOContent of Asthma CPO  Patient’s treatment preferencesPatient’s treatment preferences • ”What problems have you had using your medications?”  “Have you missed any of your medications?” • “What questions do you have about your asthma action plan?”  Can we make it easier? • “Describe for me how you know when to call the doctor or go to the hospital”  Quality of LifeQuality of Life • ““What things does your asthma make difficultWhat things does your asthma make difficult to do?”to do?”
    35. 35. 35 Content of Asthma CPOContent of Asthma CPO  Teach or review all educational strategies:Teach or review all educational strategies: • Self-assessment of asthma control • Relevant environmental control or avoidance strategies (smoke, pets, dust, mold) • Review all medications • Use of written asthma action plan • What to do when asthma gets worse  What will happen at your next visit:What will happen at your next visit: • Review action plan, proper medication and device use, a physical examination, (spirometry). EPR3, 2007
    36. 36. 36 Control: ImpairmentControl: Impairment
    37. 37. 37 Long term control medication Dose Duration Problems ICS (daily dose) LTRA LABA Other Significant exacerbations Number Dates Notes Exacerbations (number/month) Oral corticosteroid courses (number/year) Hospitalizations (number per year) Risk and Responsiveness
    38. 38. 38 Assessment and Plan Assessment Control poor  Inadequate Optimal Side Effects Prohibitive Acceptable Minimal Criteria met for step up (control worse, exacerbation in past 3 months) Criteria met for step down: (control adequate, stable for 3 months, not high-risk season, no≥ active co-morbidity) Adherence: Good Fair Poor Problems: Treatment Plan Step up: level = Step down: level = Medication(s)/Dose __________________________________________________________ Follow up: weeks months by telephone office visit______
    39. 39. 39 Goals Met In Progress Notes Decrease nocturnal symptoms Decrease daytime symptoms Decrease albuterol use Improve exercise tolerance Improve school/daycare attendance Identify triggers Avoid triggers Avoid attacks Self management goal Confidence acceptable (>7) Other
    40. 40. 40 Coding Time Call Ended Call Duration  <5min  5-10 min  11-20 min  >20 min CPT Code: Telephone Care  99441 (5-10 min)  99442 (11-20 min)  99443 (>20 min) Care Plan Oversight  99339 (15-29 min)  99340 ( 30 min)≥ Provider signature (MD, DO,PNP, RN)
    41. 41. 41
    42. 42. 42
    43. 43. 43 Telephone Services 2008Telephone Services 2008  Telephone evaluation and managementTelephone evaluation and management service provided by a physician to anservice provided by a physician to an established patient, parent, or guardianestablished patient, parent, or guardian • not originating from a related E/M servicenot originating from a related E/M service provided within the previous 7 daysprovided within the previous 7 days • nor leading to an E/M service or procedurenor leading to an E/M service or procedure within the next 24 hours or soonest availablewithin the next 24 hours or soonest available appointment;appointment; • 5-30 minutes5-30 minutes of medical discussionof medical discussion • Mild Asthma exacerbationMild Asthma exacerbation  Assess, Treat, Follow upAssess, Treat, Follow up
    44. 44. 44 Acute Asthma CareAcute Asthma Care  AssessAssess: When is it mild?: When is it mild? • Dyspnea only with activityDyspnea only with activity • PEFR >70%PEFR >70% • No retractionsNo retractions • No/minimal tachypneaNo/minimal tachypnea • Little/no impairment of activityLittle/no impairment of activity • Symptoms are usually cough, mildSymptoms are usually cough, mild wheezewheeze • At least partial response to albuterolAt least partial response to albuterol
    45. 45. 45 Not for infants Not for those with severe, brittle disease or at risk of death from asthma Properly trained and equipped < 20% in this category need ER or hospital care EPR 3, 2007
    46. 46. 46 CPT Code:  99441 (5-10 min) 99442 (11-20 min) 99443 (>20
    47. 47. 47 Asthma Action Plan The colors of the traffic light will help you use your asthma medicines Date of Discharge Next Doctor’s Appointment Date: Time: Doctor’s Name Doctor’s Phone Number GO! (Green) Use these medicines EVERY DAY to prevent asthma attacks You have ALL of these: •Breathing is good •No cough or wheeze •Sleeping through the night •Can work or play Medicine How Much to Take When to Take it No Controllers Prescribed Before exercise, if needed: 2-4 puffs of Albuterol inhaler with spacer or 1 neb treatment, 5-20 minutes before exercise CAUTION (Yellow) Keep taking daily medicines (above), and add You have ANY of these: •Cough •Wheeze •Chest tight or shortness of breath •Waking at night due to cough or trouble breathing Medicine How Much to Take When to Take it No Relievers Prescribed Albuterol 2 - 6 puffs of inhaler, or 1 nebulizer treatment Every 4 hours as needed for 24-48 hours Call your doctor if you need more than 12 puffs or 4 nebs in 24 hours If you need to use your Albuterol more than 2 times a week, or if the Albuterol is not helping, CALL YOUR DOCTOR! DANGER!! (Red) Take these medicines and call your doctor Your asthma is getting worse quickly: •Albuterol is not helping within 15-20 minutes •Breathing is hard and fast •Ribs show •Lips or fingernails are blue •Trouble walking or talking Medicine How Much to Take When to Take it Albuterol 4 - 6 puffs of inhaler, or 1 nebulizer treatment Give Albuterol treatment every 15-20 minutes, up to 3 times in a row •Get help from a doctor now! If you cannot contact your doctor, go to the ER or call 911. Do NOT wait! •See your doctor within 3-5 days of an ER visit or hospitalization oitems that trigger your asthma and things that could make your asthma worse:Tobacco
    48. 48. 48 SummarySummary  Use CPO to monitor treatment ofUse CPO to monitor treatment of chronic asthma (chronic asthma (99339, 99340)99339, 99340) • Treatment changes: step up or downTreatment changes: step up or down • Bridge between office visits and inBridge between office visits and in person monitoringperson monitoring  Management of mild exacerbationsManagement of mild exacerbations • Telephone visit codes (99441, 99442,Telephone visit codes (99441, 99442, 99443)99443)
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