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This section presents several clinical personas that help to illustrate its representation in a PCDE bundle. 

Persona / Use Case Scenario #1: Transition of services - covered medications and devices

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

Coverage Transition: Commercial to Medicare Advantage Plan

Former Coverage Info:

  • Payor Organization: MARYLAND CAPITAL INSURANCE COMPANY
  • Subscriber: Patient
  • PolicyHolder: Patient
  • Relationship of subscriber to policyholder: Self
  • Coverage Class: Plan, id: CLASSPLAN01

***Scenario 1 PCDE Bundle Example here


Clinical data represented is below:

Patient Demographics Codes:

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

http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex

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

urn:oid:2.16.840.1.113883.6.238

2106-3

US Core race category
Not Hispanic or LatinoCDC race and ethnicity 

urn:oid:2.16.840.1.113883.6.238

2186-5

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


Active Treatments:

Relevant metadata – schedule, supplier, duration of therapy, ordering provider

  • Home Oxygen Therapy – 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
  • Positive Airway Pressure Therapy
    • 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 Device and supplies

        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
  • Pulse Oximeter
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: *****( In Draft- NT)

  • Dependent / Pediatric /

  • Medicaid - Chemo -MaryKay
  • Wheelchairs/Orthotics- Claims( imaging system tiff/pdf) / Infusion Services / Bone grafting - Sx/ Inpatient * switching insurance over the year end
  • Persona: 56 yo F Glenda Goodwitch with uncontrolled Type 2 DM on oral agents , with a frozen shoulder.

  • Coverage Transition: 1) Primary Insurance Switched from Commercial Plan A to Commercial Plan 2) Secondary Insurance : Unchanged

Former Coverage Info:

  • Payor Organization: MARYLAND CAPITAL INSURANCE COMPANY

  • Subscriber: Patient

  • PolicyHolder: Patient

  • Relationship of subscriber to policyholder: Self

  • Coverage Class: Plan, id: CLASSPLAN01

New Coverage Info:

  • Payor Organization: SEABREEZE INSURANCE COMPANY

  • Subscriber: Patient

  • PolicyHolder: Patient

  • Relationship of subscriber to policyholder: Self

  • Coverage Class: Plan, id: CLASSFGRAF08

Secondary Payor Coverage Info: ***** Approval of Brand by sec when denied by Pri.

  • Payor Organization: CAPHAZEL  INSURANCE COMPANY

  • Subscriber: Patient

  • PolicyHolder: Patient's Partner

  • Relationship of subscriber to policyholder: Self

  • Coverage Class: Plan, id: CLASSSTIXX01

***Scenario 2 PCDE Bundle Example here (TBD).

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.”

Type 2 DM on OHA 

Diabetes Mellitus

ICD-10-CM

E11.65

Type 2 diabetes mellitus with other specified complications

Patient has chronic wounds

Diabetes Mellitus

SNOMED-CT

237599002

Insulin treated type 2 diabetes mellitus (disorder)


Adhesive Capsulitis ***

  • Glycosylated Hb( Hba1c)- LOINC//  Study date -  Order Date1 /Order Date 2 

  • Prior authorizations: 

  • Metformin-- 06/11/2019-06/11/2020

  • Tradjenta --6/12/2020 - Current

  • Provider: Dokter Bronsig

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

Non-DME Supplies: 

    • Diabetes: 

      • Glucose testing strips

        Blood glucose testing strips

        HCPCS

        A4253

        Blood 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

        Lancets

        HCPCS

        A4259

        Lancets, per box of 100

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

Syringes with needles

Syringes

HCPCS

S8490

Insulin syringes (100 syringes, any size)

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

DME:

    • Glucometer–investigate coverage patterns for glucometers

      Glucometer

      HCPCS

      E0607

      Home blood glucose monitor

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

      95250 for sensor placement and 95251 for data interpretation ***** Denied by Primary. ***** Approved by Secondary insurer

MEDICATIONS

Metformin

NDC

0310652004

1 CARTRIDGE in 1 TRAY > .65 mL in 1 CARTRIDGE

exenatide Pen Injector

5mcg BIDAC (2x/day) sq

Metformin

RxNorm

1653616

exenatide Pen Injector



Tradjenta BID


Tradjenta

NDC

0310652004

1 CARTRIDGE in 1 TRAY > .65 mL in 1 CARTRIDGE

exenatide Pen Injector

5mcg BIDAC (2x/day) sq

Tradjenta

RxNorm

1653616

exenatide Pen Injector



Consults

  • Specialty Care: Endocrinology-- may require procedures to treat, unclear if these would be scheduled

    Endocrinology

    consult

    SNOMED-CT

    306278007

    Referral to endocrinologist (procedure)

    Active referral, not yet seen: to Joe See, MD, endocrinology, referral for diabetes management

    Within next 1 months

  • Specialty Care: Ophthalmology-- may require procedures to treat, unclear if these would be scheduled

    Opthalmology consult

    SNOMED-CT

    183543004

    Ophthalmological referral

    Active referral, not yet seen: to Joe See, MD, ophthalmology, referral for eye exam with retinal imaging

    Within next 3 months

    • Could consider CKD/renal as part of this use case ????? 

  • Physical Therapy– consider how to categorize ancillary care vs home services

    Physical Therapy

    CPT

    97597

    Wound 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.



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