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Gather data from: CRD (Coverage Requirements of Discovery) use cases, DTR (Documentation Templates and Payer Rules), Prior Auth

Persona / Use Case Scenario #1: Advanced Chronic Obstructive Pulmonary Disease (COPD) / Obstructive Sleep Apnea (OSA)

Persona: Joe P. Smith is a 65 yo white male with end stage COPD and OSA.

Coverage Transition: Commercial to MA

Former Coverage Info:

  • Subscriber: Patient
  • PolicyHolder: Patient
  • Relationship of subscriber to policyholder: Self
  • Coverage Class: Plan, id: CLASSPLAN01

Patient Demographics Codes:

TermCodingSystemCodeAdditional Comments
MaleHL7 administrative gendermaleUS Core Patient requires both administrative gender and Birth Sex

MUS Core Patient requires both gender and Birth Sex
WhiteCDC race and ethnicity 



US Core race category
Not Hispanic or LatinoCDC race and ethnicity 



US Core ethnicity category

*Diagnosis Codes: COPD and OSA

ICD-10-CM at a minimum, ok to use a SNOMED-CT translation code if available *note what is allowed in HIPPA 837 Claims requirements

COPD (chronic obstructive pulmonary disease)ICD-10J44.9billable, generic code for COPD, does not indicate an active exacerbation
COPD (chronic obstructive pulmonary disease)SNOMED-CT313299006Severe COPD
OSA (obstructive sleep apnea)ICD-10G47.33billable
OSA (obstructive sleep apnea)SNOMED-CT78275009synonym exists for adult: 1101000119103

Goal: COPD: Maintain daily ADLs without episodes of hypoxia

Goal: OSA: Achieve restful sleep without periods of apnea

Active Treatments: relevant metadata – schedule, supplier, duration of therapy, ordering provider

  • Home O2 – 2L daytime, 4L nighttime – 
    • HCPCS: E0441: Stationary oxygen contents, gaseous, 1 month’s supply = 1 unit Code represents furnishing oxygen contents for 1 month.
      • Unclear how to code for the instructions in a structured way– this is generally an issue in the devices
  • DME: Class (from order), Make, Model, Date Provided, Date Expiring/Replacement?, GUDID?, Instructions on how to use?(probably not) * likely to have prior auth 
    • CPAP

      CPAP (continuous positive airway pressure) deviceHCPCSE0601Continuous airway pressure (CPAP/APAP) device
      CPAP maskHCPCSA7030Full Face Mask used with Positive Airway Pressure (CPAP/BiPAP/APAP) Device
    • Oxygen supplies (Canisters, concentrators, cannulas)
      • HCPCS: E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing Portable Oxygen Equipment
      • see attached sheet for additional codes
    • Nebulizer
Nebulizer machineHCPCSE0570Nebulizer, with compressor
  •          Oxymeter-- use as needed for checking oxygen level

    E0445Oximeter device for measuring blood oxygen levels non-invasively
  • Medications: 
    • Spiriva inhaler

      Spiriva inhaler (60 ACTUAT tiotropium 0.0025 MG/ACTUAT Metered Dose Inhaler [Spiriva])NDC00597010061Metered dose inhaler

      use 2 puffs daily inhaled in the morning

      Spiriva inhaler (60 ACTUAT tiotropium 0.0025 MG/ACTUAT Metered Dose Inhaler [Spiriva])RxNorm1552004Metered dose inhaler
    • Advair inhaler
      Advair (fluticasone / salmeterol Metered Dose Inhaler [Advair])NDC00173069500Metered dose inhaler

      Use 2 puffs twice a day inhaled

      Advair (fluticasone / salmeterol Metered Dose Inhaler [Advair])RxNorm896190Metered dose inhaler
    • Duonebs inhaled via nebulizer
      Duoneb (Albuterol 0.833 MG/ML / Ipratropium Bromide 0.167 MG/ML Inhalant Solution [DuoNeb])NDC49502067260Inhalant solution

      Use 1 dose every 4 hours inhaled as needed for wheezing or shortness of breath

      '49502067260' is not recognized by the FHIR validator.  Removed the NDC coding and represented just with RxNorm for the example.

      Duoneb (Albuterol 0.833 MG/ML / Ipratropium Bromide 0.167 MG/ML Inhalant Solution [DuoNeb])RxNorm1437704Inhalant solution
  • Routine complete PFTs  with spirometry
    • Due annually-- next test 12/05/2019
    • Last test 12/05/2018

      Pulmonary function test with spirometryCPT94726Recommended screening-- could be used to display guideline

      Next test due 12/05/2019

  • Home monitoring-- see oxymeter above-- if additional monitoring is appropriate discuss with group
  • Specialty care: 
    • Pulmonary Consult

      Pulmonary consultCPT92214Provider name: Susan Watson, MD, pulmonology, level 4 visit-- unclear if this is correct because would you send consult as active treatment?

      Performed July 1, 2019

  • Prior authorizations: specific to insurer, patient and plan-- there is not a category-- would be an optional component for which the payer would want the information about what was provided and the determination

Persona/Use Case Scenario #2: Diabetes

  • Gather data from: Wound care implementation guide/data set, ADA?
  • Persona: 82 yo F Glenda Goodwitch with insulin-dependent DM for 19 years, has multiple complications including chronic  wounds and retinopathy
  • Coverage transition: MA to MA
  • Consider impact of Medicare supplemental plan?

Diagnosis Codes:

Diabetes Mellitus: SNOMED-CT 237599002 | Insulin treated type 2 diabetes mellitus (disorder) or ICD-10-CM E11.65 “Type 2 diabetes mellitus with other specified complications.”

Diabetes MellitusICD-10-CME11.65Type 2 diabetes mellitus with other specified complicationsPatient has chronic wounds
Diabetes MellitusSNOMED-CT237599002Insulin treated type 2 diabetes mellitus (disorder)

Chronic foot ulcer related to diabetes:

Diabetic foot ulcerICD-10-CML97.509

Non-pressure chronic ulcer of other part of unspecified foot with unspecified severity

Diabetic foot ulcerSNOMED-CT110171000119107

Ulcer of lower extremity due to diabetes mellitus type 2 (disorder)

  • Goal:
    • Diabetes Glucose Control: Hba1c <7.5
    • Not achieved
    • Wound Care: Closure of foot ulcer
    • Not achieved
  • Provider: Dokter Bronsig
  • Active Treatments: relevant metadata – schedule, supplier, duration of therapy, ordering provider
  • Non-DME Supplies: 
    • Diabetes: 
      • Glucose testing strips

        Blood glucose testing stripsHCPCSA4253Blood glucose test or reagent strips for home blood glucose monitor, 50 strips

        Unclear how often this order renews or how many units are provided at once

      • Lancets

        LancetsHCPCSA4259Lancets, per box of 100

        Unclear how often this order renews or how many units are provided at once

      • Syringes with needles

        SyringesHCPCSS8490Insulin syringes (100 syringes, any size)

        Unclear how often this order renews or how many units are provided at once

    • Wound care: this care plan may be optional in this use case?
  • DME:
    • Glucometer–investigate coverage patterns for glucometers

      GlucometerHCPCSE0607Home blood glucose monitor

      this is technically a device-- is this the correct code?

  • Medications:
    • Humalog SSI

      Lispro SSINDC00027510011 VIAL in 1 CARTON > 10 mL in 1 VIALINSULIN LISPRO 100 [iU]/mL, syn Humalog

      Sliding scale sq TIDAC, for BG<180 0 units, for BG180-240 2 units, for BG 241-300 4 units, for BG301+ 6 units, for BG>400, call MD

      Lispro SSIRxNorm242120insulin lispro 100 UNT/ML Injectable Solution

    • Lantus 40 u BID
      LantusNDC000885020011 SYRINGE in 1 PACKAGE > 3 mL in 1 SYRINGE3 ML Insulin Glargine 100 UNT/ML Pen Injector [Lantus]40 u sq BID
      Lantus solostar
    • Exenatide BID

      ExenatideNDC03106520041 CARTRIDGE in 1 TRAY > .65 mL in 1 CARTRIDGEexenatide Pen Injector

      5mcg BIDAC (2x/day) sq


      exenatide Pen Injector

    • Antibiotics*-- fixed duration ? – can use for future use case with active treatment that is temporary
    • Bacitracin?
  • Diabetes Care Management Program – from payer, provider, outside resource? would all data be similarly available?

    Chronic Care Management, Diabetes and wound care,CPT99487Complex chronic care management services, with the following required elements: ● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient ● Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline ● Establishment or substantial revision of a comprehensive care plan ● Moderate or high complexity medical decision making ● 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

    Not sure this is the right code-- would payer care managment be physician supervised? Can this be billed remotely?

  • Specialty Care: Ophthalmology-- may require procedures to treat, unclear if these would be scheduled
    Opthalmology consultSNOMED-CT183543004Ophthalmological referralActive referral, not yet seen: to Joe See, MD, ophthalmology, referral for eye exam with retinal imagingWithin next 3 months
    • Could consider CKD/renal as part of this use case
  • Ancillary Care: Wound care, Home RN – consider how to categorize ancillary care vs home services

    Home health wound therapyCPT97597Wound therapy, home

    CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their Plan of Care. If it is a physician or nonphysician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care.

  • Prior authorizations: 
  • Exenatide-- 06/11/2019-06/11/2020

Personal / Use Case Scenario #3: Liver Transplant

  • Persona: 55 yo with liver transplant for NASH/ETOH, comorbid depression
  • Coverage Transition: Commercial to Commercial
  • Diagnosis Codes: TBD
  • Active Treatments:
  • Medications:
    • Immunosuppression
  • Counseling/mental health services
  • Substance abuse follow up
  • Specialty Care: Transplant Surgery
  • Transplant Coordinator and Care Management
  • Past treatments? – Transplant surgery, pre-transplant therapy?
  • Prior authorizations
  • Notes from discussion: 
  • What is the role of supplemental coverage? Would they have clinical data relevant to these use cases or the exchange of data?
  • Past Medical History: what if any PMH should be transmitted? How do we determine what is relevant and what is not
    • PMH will be transmitted in as much as it is relevant to current conditions/treatments

TERMINOLOGY SPREADSHEET:  Google sheet with terminology content

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