IHS Tobacco 5As presentation in NAO

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Powerpoint presentation presented at the 2009 IHS Best Practices meeting in Nashville.
Covers the 5As and documentation of patient education and tobacco health factors in the RPMS EHR.

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  • Ask about tobacco use at every visit and document responses using the Tobacco health factors

  • Advise the patient to quit tobacco abuse using a personalized, positive and motivating statement
    “quitting tobacco is the most important thing you can do to protect your health”
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments
  • Chris will show the information that can be added to the education code – mention free text comments






  • Assess how willing someone is to quit –
    If they are ready to quit, in which case you can add a goal to the patient education code
    If they are not ready to quit, you can document that a goal was not set
    Patients who do not use tobacco or have already quit should receive positive feedback and continued motivation to not start
  • If wiling to quit, set a quit date, remove tobacco products from the environment, get support for the patient (identify family and friends). Discuss past quit attempts and the things that helped as well as the things that led to relapse. Review the benefits of quitting tobacco.
    Add a goal to the patient education code

  • Schedule follow-up visits to review progress toward quitting.
    Refer patients as appropriate using consults in EHR or other mechanisms and patient education
    Provide guidance on what to do if there is a relapse
    Review medications and other treatments
    Refer to quit lines for additional support and document using patient education – this is a new code that will be released with the next PEPC manual














  • IHS Tobacco 5As presentation in NAO

    1. 1. 2010 Nashville Area Health Summit DOCUMENTING TOBACCO INTERVENTIONS Chris Lamer, PharmD, MHS, BCPS, CDE
    2. 2. Percentage of tobacco users who received a tobacco cessation interventions documented
    3. 3. Brief Interventions Using the 5 A’s
    4. 4. Brief Intervention • Brief interventions (< 3 minutes) • 5 A’s – Ask if they use tobacco – Advise to quit – Assess willingness to make quit attempt – Assist in making quit attempt – Arrange for follow up contact
    5. 5. Brief Intervention • Brief interventions (< 3 minutes) • 5 A’s – Ask if they use tobacco – Advise to quit – Assess willingness to make quit attempt – Assist in making quit attempt – Arrange for follow up contact
    6. 6. Ask Advise Assess Assist 1. Ask the patient if he or she uses tobacco products (cigarettes, snuff, dip, etc.). 2. Ask the patient if he or she uses tobacco products for cultural or religious purposes. 3. Ask the patient if he or she is exposed to tobacco smoke at work. 4. Ask the patient if anyone uses tobacco products at home. 5. Document the health factor screening results using the values in the table.
    7. 7. Ask Advise Assess Assist • The single most important step in addressing tobacco use and dependence is: SCREENING FOR TOBACCCO USE • Recommendation: reassess at every visit and document as a health factor *U.S. DHHS Treating Tobacco Use and Dependence
    8. 8. Assess using Health Factors
    9. 9. Ask Advise Assess Assist • Health Factors – Non-Tobacco User ---> RENAMED to Never Used Tobacco – Current Smoker – Current Smokeless – Current Smoker & Smokeless – Cessation Smoker – Cessation Smokeless – Previous Smoker – Pervious Smokeless – Ceremonial Use Only – Smoker in the Home – Smoke Free Home – Exposure to Environmental Tobacco Smoke
    10. 10. Tobacco Health Factors
    11. 11. Ask Advise Assess Assist • Patient Education
    12. 12. Ask Advise Assess Assist
    13. 13. Ask Advise Assess Assist Readines Level of Sub- Topic s to Understandi Provider Time Topic Learn ng
    14. 14. Ask Advise Assess Assist Readines Level of Sub- Topic s to Understandi Provider Time Topic Learn ng -Mnemonic (TO, HTN) -ICD9 Code -CPT Code
    15. 15. Ask Advise Assess Assist Readines Level of Sub- Topic s to Understandi Provider Time Topic Learn ng -Mnemonic (TO, HTN) -ICD9 Code -CPT Code AP - Anatomy & Physiology HM - Home Management N - Nutrition C - Complications HY - Hygiene P - Prevention DP - Disease Process LA - Lifestyle Adaptations PRO - Procedures EQ - Equipment L – Literature S - Safety EX - Exercise M – Medications TE - Tests FU - Follow-up MNT – Med Nutrition Tx TX - Treatment
    16. 16. Ask Advise Assess Assist Readines Level of Sub- Topic s to Understandi Provider Time Topic Learn ng Education Code -Mnemonic (TO, HTN) -ICD9 Code -CPT Code AP - Anatomy & Physiology HM - Home Management N - Nutrition C - Complications HY - Hygiene P - Prevention DP - Disease Process LA - Lifestyle Adaptations PRO - Procedures EQ - Equipment L – Literature S - Safety EX - Exercise M – Medications TE - Tests FU - Follow-up MNT – Med Nutrition Tx TX - Treatment
    17. 17. Ask Advise Assess Assist Readines Level of Sub- Topic s to Understandi Provider Time Topic Learn ng Education Code -Receptive -Eager -Mnemonic (TO, HTN) -Unreceptive -ICD9 Code -Distraction -CPT Code -Intoxication -Severity of illness AP - Anatomy & Physiology HM - Home Management N - Nutrition C - Complications HY - Hygiene P - Prevention DP - Disease Process LA - Lifestyle Adaptations PRO - Procedures EQ - Equipment L – Literature S - Safety EX - Exercise M – Medications TE - Tests FU - Follow-up MNT – Med Nutrition Tx TX - Treatment
    18. 18. Ask Advise Assess Assist Readines Level of Sub- Topic s to Understandi Provider Time Topic Learn ng Education Code -Receptive -Good -Eager -Fair -Mnemonic (TO, HTN) -Unreceptive -Poor -ICD9 Code -Distraction -Refused -CPT Code -Intoxication -Group -Severity of illness AP - Anatomy & Physiology HM - Home Management N - Nutrition C - Complications HY - Hygiene P - Prevention DP - Disease Process LA - Lifestyle Adaptations PRO - Procedures EQ - Equipment L – Literature S - Safety EX - Exercise M – Medications TE - Tests FU - Follow-up MNT – Med Nutrition Tx TX - Treatment
    19. 19. Ask Advise Assess Assist Readines Level of Sub- Topic s to Understandi Provider Time Topic Learn ng
    20. 20. Ask Advise Assess Assist Readines Level of Sub- Topic s to Understandi Provider Time Topic Learn ng TO - QT- EAGR - G - ABC - 5min
    21. 21. Adding Patient Education
    22. 22. Outcome and Standards
    23. 23. Select the code you want
    24. 24. Document Education
    25. 25. Pick Lists
    26. 26. Ask Advise Assess Assist – The patient uses tobacco and wants to quit • Provide resources and assistance – Quit line information TO-HELP – Tobacco handouts TO-L – Refer to tobacco cessation specialist TO-IR – The patient uses tobacco and does not want to quit • Provide and review tobacco treatment literature – TO-L-RECPT-G-CL-3min-GNS • Provide feedback on why they should consider quitting – The patient has used tobacco and has quit – The patient has never used tobacco • Commend and promote abstinence
    27. 27. Ask Advise Assess Assist • Set a goal and a quit date • TO-QT-G-CL-5min – GS – will quit on 6/25
    28. 28. Ask Advise Assess Assist
    29. 29. Ask Advise Assess Assist • TO-IR INFORMATION AND REFERRAL – OUTCOME: The patient/family will understand the process of referral and treatment for nicotine dependence. – STANDARDS: • Discuss sources for tobacco cessation treatment • Refer to nicotine treatment program or other resource as available. • TO-QL QUIT LINE    – OUTCOME: The patient/family will understand how to access and benefit from a tobacco quit line. – STANDARDS: • Explain to the patient/family that a quit line will enable to the patient to talk with a specialist who can helpthem plan an individualized quit method and may some times be used in coordination with other types of tobacco use treatment such as group or individual programs and/or medications. • Explain that people who use telephone counseling stop smoking at twice the rate of those who don’t get this type of help. • Provide the patient with the quite line phone number and hours of operation or assist the patient in calling the quit line during the patient encounter. • Explain how the quit line works and what the patient can expect from calling.
    30. 30. 5 A’s • Ask – screen for tobacco use every visit – Document health factor • Advise – Encourage tobacco avoidance – Document as patient education: TO-QT • Assess – determine readiness to quit – Tobacco handouts TO-L – Encourage tobacco avoidance TO-QT • Assist – help set a tobacco quit date and plan • Arrange – Arrange for follow up – Quit line information TO-HELP – Tobacco handouts TO-L – Refer to tobacco cessation specialist TO-IR
    31. 31. ICD9 Codes • International Classification of Disease ICD9 Definition Code 305.1 Tobacco Use Disorder/Dependence History of Tobacco Use V15.82
    32. 32. CPT Codes • Current Procedural Terminology) is used to describe a medical service that is provided. CPT Definition Code 99406 Tobacco-use cessation counseling visit; intermediate, greater than 3 minutes and less than 10 minutes. Document the E&M code for the visit 99407 as appropriate (99201-99215)
    33. 33. CPT Codes • S9075: Smoking Cessation Treatment • S9453: Smoking Cessation Classes, non-physician provider, per session • 99381- 99397: Preventive medicine services • 96150- 96155: Health & Behavior Assessment/Intervention (Non- physician only) • 99078: Physician educational services in a group setting
    34. 34. E&M Codes • Evaluation and Management Codes – No E&M codes specific for tobacco use disorder interventions – Document for the visit depending on the level of service provided and the setting in which it is provided E&M Code Definition Add Shows the E&M service is a Modifier separately identifiable service from 25 the smoking and tobacco-use cessation counseling service
    35. 35. Billing Medicare • Medicare Rules: – Up to two attempts per year – Maximum of four sessions per attempt – A total of eight sessions are covered in 12 months – Tobacco Use Disorder must be a SECONDARY diagnosis • 99406 for brief intervention (3-10min) • 99407 for intensive intervention (>10)
    36. 36. Quality Metrics
    37. 37. PQRI Measures (CPT Codes) Measure CPT Code Definition Inquiry 1000F and Tobacco use assessed regarding 1034F or Current smoker tobacco use 1035F or Current smokeless tobacco 1036F or Current non-smoker or 100F-8P Tobacco use not assessed/no reason noted Advising G8455 and Tobacco use cessation smokers 4000F or Tobacco use cessation intervention, to quit counseling 4001F or G8456 Tobacco use cessation intervention, pharmacologic tx or G8457 Smokeless tobacco user, not counseled to quit or G8455 and Tobacco non-user, not counseled to quit 4000F-8P SmokerNot counseled, no reason provided
    38. 38. CRS and GPRA Measures • Tobacco Use and Exposure Assessment • Tobacco Cessation (GPRA and ONM) • Comprehensive CVD-Related Assessment (GPRA)
    39. 39. Resources http://nativeamericanprograms.org 31
    40. 40. Conclusion 35

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