These exercises should be repeated every hour on a flight when you are awake.

Neck roll

With your shoulders and arms relaxed and hanging down, tilt your head to your left, hold for a few seconds, then slowly roll your head toward your back and hold for a few seconds, then slowly roll your head toward your right shoulder and hold for a few seconds, and then slowly roll your head toward your chest and hold for a few seconds. Repeat this exercise for a total of five times clockwise and then five times counterclockwise.

Shoulder roll

While in your seat with your arms on the arm rests, move both shoulders in a circular motion from front to back five times and then repeat in the opposite direction.

Shoulder stretch

While in your seat, put your left hand on your right shoulder. With your right hand, grasp your elbow and pull your left elbow toward your right side. Hold this position for 15 seconds and then switch arms and repeat the stretch with the opposite side. Repeat these stretches five times with each arm.

Knee-to-chest stretch

While in your seat, lean forward slightly and grab your knee just below the joint. Slowly pull your knee toward your chest and hold for 15 seconds. Repeat the stretch with your other knee. Repeat the cycle five times.

Ankle circles

Raise your feet off the floor and rotate them in a circular motion five times clockwise and then five times counterclockwise.

Foot pumps

With your heels on the floor, first raise your toes as high as you can and hold that position for 10 seconds. Then lower your toes until they touch the floor, and then raise your heels off the floor as much as you can, keeping your toes on the floor, and hold that position for 10 seconds. Repeat this exercise five times.

Adapted with permission from Continental Airlines

This information is provided by your physician and the Cleveland Clinic Journal of Medicine. It is not designed to replace a physician’s medical assessment and judgment.

This page may be reproduced noncommercially to share with patients. Any other reproduction is subject to Cleveland Clinic Journal of Medicine approval. Bulk color reprints are available by calling 216-444-2661.

For patient information on hundreds of health topics, see the Web site, www.clevelandclinic.org/health

These exercises should be repeated every hour on a flight when you are awake.

Neck roll

With your shoulders and arms relaxed and hanging down, tilt your head to your left, hold for a few seconds, then slowly roll your head toward your back and hold for a few seconds, then slowly roll your head toward your right shoulder and hold for a few seconds, and then slowly roll your head toward your chest and hold for a few seconds. Repeat this exercise for a total of five times clockwise and then five times counterclockwise.

Shoulder roll

While in your seat with your arms on the arm rests, move both shoulders in a circular motion from front to back five times and then repeat in the opposite direction.

Shoulder stretch

While in your seat, put your left hand on your right shoulder. With your right hand, grasp your elbow and pull your left elbow toward your right side. Hold this position for 15 seconds and then switch arms and repeat the stretch with the opposite side. Repeat these stretches five times with each arm.

Knee-to-chest stretch

While in your seat, lean forward slightly and grab your knee just below the joint. Slowly pull your knee toward your chest and hold for 15 seconds. Repeat the stretch with your other knee. Repeat the cycle five times.

Ankle circles

Raise your feet off the floor and rotate them in a circular motion five times clockwise and then five times counterclockwise.

Foot pumps

With your heels on the floor, first raise your toes as high as you can and hold that position for 10 seconds. Then lower your toes until they touch the floor, and then raise your heels off the floor as much as you can, keeping your toes on the floor, and hold that position for 10 seconds. Repeat this exercise five times.

Adapted with permission from Continental Airlines

This information is provided by your physician and the Cleveland Clinic Journal of Medicine. It is not designed to replace a physician’s medical assessment and judgment.

This page may be reproduced noncommercially to share with patients. Any other reproduction is subject to Cleveland Clinic Journal of Medicine approval. Bulk color reprints are available by calling 216-444-2661.

For patient information on hundreds of health topics, see the Web site, www.clevelandclinic.org/health

These exercises should be repeated every hour on a flight when you are awake.

Neck roll

With your shoulders and arms relaxed and hanging down, tilt your head to your left, hold for a few seconds, then slowly roll your head toward your back and hold for a few seconds, then slowly roll your head toward your right shoulder and hold for a few seconds, and then slowly roll your head toward your chest and hold for a few seconds. Repeat this exercise for a total of five times clockwise and then five times counterclockwise.

Shoulder roll

While in your seat with your arms on the arm rests, move both shoulders in a circular motion from front to back five times and then repeat in the opposite direction.

Shoulder stretch

While in your seat, put your left hand on your right shoulder. With your right hand, grasp your elbow and pull your left elbow toward your right side. Hold this position for 15 seconds and then switch arms and repeat the stretch with the opposite side. Repeat these stretches five times with each arm.

Knee-to-chest stretch

While in your seat, lean forward slightly and grab your knee just below the joint. Slowly pull your knee toward your chest and hold for 15 seconds. Repeat the stretch with your other knee. Repeat the cycle five times.

Ankle circles

Raise your feet off the floor and rotate them in a circular motion five times clockwise and then five times counterclockwise.

Foot pumps

With your heels on the floor, first raise your toes as high as you can and hold that position for 10 seconds. Then lower your toes until they touch the floor, and then raise your heels off the floor as much as you can, keeping your toes on the floor, and hold that position for 10 seconds. Repeat this exercise five times.

Adapted with permission from Continental Airlines

This information is provided by your physician and the Cleveland Clinic Journal of Medicine. It is not designed to replace a physician’s medical assessment and judgment.

This page may be reproduced noncommercially to share with patients. Any other reproduction is subject to Cleveland Clinic Journal of Medicine approval. Bulk color reprints are available by calling 216-444-2661.

For patient information on hundreds of health topics, see the Web site, www.clevelandclinic.org/health

Optimal surgical management of patients with transposition of the great arteries, ventricular septal defect, and left ventricular outflow obstruction is still considered controversial. Although the Rastelli operation is the most commonly performed procedure, the Réparation à l'Etage Ventriculaire procedure and Metras modification yielded the best long-term results for both survival and event-free survival, according to a retrospective study of 146 patients who underwent surgery from 1980 to 2008 in eight European hospitals.

The multicenter study compared use and outcomes of several different surgical operations for transposition of the great arteries (TGA), ventricular septal defect (VSD), and left ventricular outflow obstruction (LVOTO), according to a report published in the European Journal of Cardio-thoracic Surgery.

A total of 141 patients had TGA, VSD, and LVOTO; 5 patients had the TGA type of double-outlet right ventricle (DORV) with LVOTO. Only those patients for whom the surgical method chosen was equivalent to those for TGA, VSD, and LVOTO were included in the study; all other DORV types were excluded, according to Dr. Mark Gerard Hazekamp of Leids Universitair Medisch Centrum, Leiden, the Netherlands, and his colleagues from various European universities on behalf of the European Congenital Heart Surgeons Association.

The procedures investigated were the Rastelli (82 patients), arterial (24) and atrial (5) switch operation with relief of LVOTO, Reparation l'Etage Ventriculaire (REV) procedure (7), and Metras modification (24), as well as the Nikaidoh (4). The type of surgery used has traditionally been different in different countries, they said, with the REV procedure and Metras modification mainly in France and the Rastelli procedure being the norm in most other countries.

Patients had a median age at operation of 21.5 months (range 0.2-165.1 months) and a median weight of 10 kg (range 2.0-41.0 kg). Pulmonary stenosis was found in 119 patients, while 27 had pulmonary atresia. LVOTO was solely valvar in 24% of the patients, only subvalvar in 37% of patients, and multilevel in 39%.

The location of the most important VSD was known in 143 patients, with outlet septum in 102, inlet septum in 14, trabecular septum in 3, and a combination of the three in 24 patients. The great majority of the 140 patients for whom data were available had great artery commitment of the biggest VSD: to the aorta in 60, the pulmonary artery in 32, and doubly committed to both in 19. Only 29 patients had noncommitment of one of the great arteries to the VSD.

Overall postoperative survival was 92% at 1 month, 88% at 1 year, 88% at 10 years, and 58% at 20 years. Events were followed as an outcome and were defined as death, reoperation, transcatheter intervention, or cardiac transplantation. The frequent necessity of reintervention (40.7% over follow-up) caused the overall event-free survival to be lower: 85% at 1 month, 80% at 1 year, 45% at 10 years, and 26% at 20 years (Euro. J. Cardiothorac. Surg. 2010;38:699-706).

There were 41 surgical reinterventions and 20 percutaneous procedures, with the most frequent cause of reoperation being RVOT obstruction, including conduit failure (25.0%), followed by LVOT obstruction (7.9%), residual VSD closure (7.1%), and pulmonary artery plasty (4.3%).

In multivariate analysis, age at the corrective surgery, year of the operation, and type of operation were significant predictors for reoperation and trans-catheter intervention, in general, as well as for RVOT reoperation/intervention. The younger the patient at the time of operation, the higher the risk of later reoperation, leading the researchers to speculate that the more recent the surgery, the less the probability that a patient would undergo reoperation.

Reoperation for RVOTO was most common in patients with a Rastelli operation, according to the authors.

"Although there are some differences between Rastelli outcomes among different groups, the all-over rates of freedom from reoperation and, especially, event-free survival, are not satisfactory with event-free survival rates at 10 years that vary from 24% to 49%," they said.

"The Rastelli procedure was a significant independent risk factor for re-operation, with the REV/Metras and the Nikaidoh having the lowest re-intervention rates," they wrote.

They indicated more patients need to be studied with longer follow-up, especially for the Nikaidoh technique.

The authors had no disclosures.

Optimal surgical management of patients with transposition of the great arteries, ventricular septal defect, and left ventricular outflow obstruction is still considered controversial. Although the Rastelli operation is the most commonly performed procedure, the Réparation à l'Etage Ventriculaire procedure and Metras modification yielded the best long-term results for both survival and event-free survival, according to a retrospective study of 146 patients who underwent surgery from 1980 to 2008 in eight European hospitals.

The multicenter study compared use and outcomes of several different surgical operations for transposition of the great arteries (TGA), ventricular septal defect (VSD), and left ventricular outflow obstruction (LVOTO), according to a report published in the European Journal of Cardio-thoracic Surgery.

A total of 141 patients had TGA, VSD, and LVOTO; 5 patients had the TGA type of double-outlet right ventricle (DORV) with LVOTO. Only those patients for whom the surgical method chosen was equivalent to those for TGA, VSD, and LVOTO were included in the study; all other DORV types were excluded, according to Dr. Mark Gerard Hazekamp of Leids Universitair Medisch Centrum, Leiden, the Netherlands, and his colleagues from various European universities on behalf of the European Congenital Heart Surgeons Association.

The procedures investigated were the Rastelli (82 patients), arterial (24) and atrial (5) switch operation with relief of LVOTO, Reparation l'Etage Ventriculaire (REV) procedure (7), and Metras modification (24), as well as the Nikaidoh (4). The type of surgery used has traditionally been different in different countries, they said, with the REV procedure and Metras modification mainly in France and the Rastelli procedure being the norm in most other countries.

Patients had a median age at operation of 21.5 months (range 0.2-165.1 months) and a median weight of 10 kg (range 2.0-41.0 kg). Pulmonary stenosis was found in 119 patients, while 27 had pulmonary atresia. LVOTO was solely valvar in 24% of the patients, only subvalvar in 37% of patients, and multilevel in 39%.

The location of the most important VSD was known in 143 patients, with outlet septum in 102, inlet septum in 14, trabecular septum in 3, and a combination of the three in 24 patients. The great majority of the 140 patients for whom data were available had great artery commitment of the biggest VSD: to the aorta in 60, the pulmonary artery in 32, and doubly committed to both in 19. Only 29 patients had noncommitment of one of the great arteries to the VSD.

Overall postoperative survival was 92% at 1 month, 88% at 1 year, 88% at 10 years, and 58% at 20 years. Events were followed as an outcome and were defined as death, reoperation, transcatheter intervention, or cardiac transplantation. The frequent necessity of reintervention (40.7% over follow-up) caused the overall event-free survival to be lower: 85% at 1 month, 80% at 1 year, 45% at 10 years, and 26% at 20 years (Euro. J. Cardiothorac. Surg. 2010;38:699-706).

There were 41 surgical reinterventions and 20 percutaneous procedures, with the most frequent cause of reoperation being RVOT obstruction, including conduit failure (25.0%), followed by LVOT obstruction (7.9%), residual VSD closure (7.1%), and pulmonary artery plasty (4.3%).

In multivariate analysis, age at the corrective surgery, year of the operation, and type of operation were significant predictors for reoperation and trans-catheter intervention, in general, as well as for RVOT reoperation/intervention. The younger the patient at the time of operation, the higher the risk of later reoperation, leading the researchers to speculate that the more recent the surgery, the less the probability that a patient would undergo reoperation.

Reoperation for RVOTO was most common in patients with a Rastelli operation, according to the authors.

"Although there are some differences between Rastelli outcomes among different groups, the all-over rates of freedom from reoperation and, especially, event-free survival, are not satisfactory with event-free survival rates at 10 years that vary from 24% to 49%," they said.

"The Rastelli procedure was a significant independent risk factor for re-operation, with the REV/Metras and the Nikaidoh having the lowest re-intervention rates," they wrote.

They indicated more patients need to be studied with longer follow-up, especially for the Nikaidoh technique.

The authors had no disclosures.

Optimal surgical management of patients with transposition of the great arteries, ventricular septal defect, and left ventricular outflow obstruction is still considered controversial. Although the Rastelli operation is the most commonly performed procedure, the Réparation à l'Etage Ventriculaire procedure and Metras modification yielded the best long-term results for both survival and event-free survival, according to a retrospective study of 146 patients who underwent surgery from 1980 to 2008 in eight European hospitals.

The multicenter study compared use and outcomes of several different surgical operations for transposition of the great arteries (TGA), ventricular septal defect (VSD), and left ventricular outflow obstruction (LVOTO), according to a report published in the European Journal of Cardio-thoracic Surgery.

A total of 141 patients had TGA, VSD, and LVOTO; 5 patients had the TGA type of double-outlet right ventricle (DORV) with LVOTO. Only those patients for whom the surgical method chosen was equivalent to those for TGA, VSD, and LVOTO were included in the study; all other DORV types were excluded, according to Dr. Mark Gerard Hazekamp of Leids Universitair Medisch Centrum, Leiden, the Netherlands, and his colleagues from various European universities on behalf of the European Congenital Heart Surgeons Association.

The procedures investigated were the Rastelli (82 patients), arterial (24) and atrial (5) switch operation with relief of LVOTO, Reparation l'Etage Ventriculaire (REV) procedure (7), and Metras modification (24), as well as the Nikaidoh (4). The type of surgery used has traditionally been different in different countries, they said, with the REV procedure and Metras modification mainly in France and the Rastelli procedure being the norm in most other countries.

Patients had a median age at operation of 21.5 months (range 0.2-165.1 months) and a median weight of 10 kg (range 2.0-41.0 kg). Pulmonary stenosis was found in 119 patients, while 27 had pulmonary atresia. LVOTO was solely valvar in 24% of the patients, only subvalvar in 37% of patients, and multilevel in 39%.

The location of the most important VSD was known in 143 patients, with outlet septum in 102, inlet septum in 14, trabecular septum in 3, and a combination of the three in 24 patients. The great majority of the 140 patients for whom data were available had great artery commitment of the biggest VSD: to the aorta in 60, the pulmonary artery in 32, and doubly committed to both in 19. Only 29 patients had noncommitment of one of the great arteries to the VSD.

Overall postoperative survival was 92% at 1 month, 88% at 1 year, 88% at 10 years, and 58% at 20 years. Events were followed as an outcome and were defined as death, reoperation, transcatheter intervention, or cardiac transplantation. The frequent necessity of reintervention (40.7% over follow-up) caused the overall event-free survival to be lower: 85% at 1 month, 80% at 1 year, 45% at 10 years, and 26% at 20 years (Euro. J. Cardiothorac. Surg. 2010;38:699-706).

There were 41 surgical reinterventions and 20 percutaneous procedures, with the most frequent cause of reoperation being RVOT obstruction, including conduit failure (25.0%), followed by LVOT obstruction (7.9%), residual VSD closure (7.1%), and pulmonary artery plasty (4.3%).

In multivariate analysis, age at the corrective surgery, year of the operation, and type of operation were significant predictors for reoperation and trans-catheter intervention, in general, as well as for RVOT reoperation/intervention. The younger the patient at the time of operation, the higher the risk of later reoperation, leading the researchers to speculate that the more recent the surgery, the less the probability that a patient would undergo reoperation.

Reoperation for RVOTO was most common in patients with a Rastelli operation, according to the authors.

"Although there are some differences between Rastelli outcomes among different groups, the all-over rates of freedom from reoperation and, especially, event-free survival, are not satisfactory with event-free survival rates at 10 years that vary from 24% to 49%," they said.

"The Rastelli procedure was a significant independent risk factor for re-operation, with the REV/Metras and the Nikaidoh having the lowest re-intervention rates," they wrote.

They indicated more patients need to be studied with longer follow-up, especially for the Nikaidoh technique.

The authors had no disclosures.

Children with autism rely heavily on proprioception, unlike children with other developmental motor impairments or typically developing children.

PROVIDENCE, RI—Children with autism spectrum disorder form a representation of internal models that places an unusually strong reliance on proprioception, according to research presented at the 39th National Meeting of the Child Neurology Society.

“This anomalous motor learning is specific to autism spectrum disorder, rather than a general deficit of all populations with developmental motor impairments, as children with ADHD did not generalize differently than typically developing children,” reported Stewart H. Mostofsky, MD, research scientist at the Kennedy Krieger Institute and Associate Professor of Neurology, Johns Hopkins University School of Medicine, Baltimore, and colleagues. “Our results suggest that autism-associated impairment in understanding actions of others may be a consequence of the fact that in learning to perform actions, children with autism place a greater than normal reliance on their own proprioception while discounting the visual consequences of their actions.”

The researchers analyzed 25 children with autism (mean age, 10.31), 16 with ADHD (mean age, 10.66), and 39 typically developing children (mean age, 10.82). As part of a game, each child held the handle of a robotic arm, trying to capture animals that had escaped from a zoo. An animal would appear at a target location 8 cm away; if the child reached the target in time, the animal was captured and the child was given a point.

“Analyses revealed that all groups were able to effectively adapt their arm movement,” stated Dr. Mostofsky’s group. “However, generalization patterns were markedly different. There was a significant interaction between diagnostic group and relative generalization to targets 2 and 3. Posthoc analyses revealed this difference was due to significantly greater generalization of the autism group in the intrinsic (proprioceptive) coordinate system as compared to typically developing children. In contrast, there was no significant difference in generalization between ADHD and typically developing children.”

Regression analyses revealed that among all groups, generalization in the intrinsic (proprioceptive) coordinate system (ie, to target 3) was a significant predictor of social ability, such that greater social impairment was predicted by increased force for target 3, noted Dr. Mostofsky and colleagues. “Further,” the researchers concluded, “for the children with autism, increased force for target 3 predicted impaired social interaction. In addition, increased generalization to target 3 also predicted impaired imitation ability, as assessed on a praxis examination, as well as impairment in motor control.”

Children with autism rely heavily on proprioception, unlike children with other developmental motor impairments or typically developing children.

PROVIDENCE, RI—Children with autism spectrum disorder form a representation of internal models that places an unusually strong reliance on proprioception, according to research presented at the 39th National Meeting of the Child Neurology Society.

“This anomalous motor learning is specific to autism spectrum disorder, rather than a general deficit of all populations with developmental motor impairments, as children with ADHD did not generalize differently than typically developing children,” reported Stewart H. Mostofsky, MD, research scientist at the Kennedy Krieger Institute and Associate Professor of Neurology, Johns Hopkins University School of Medicine, Baltimore, and colleagues. “Our results suggest that autism-associated impairment in understanding actions of others may be a consequence of the fact that in learning to perform actions, children with autism place a greater than normal reliance on their own proprioception while discounting the visual consequences of their actions.”

The researchers analyzed 25 children with autism (mean age, 10.31), 16 with ADHD (mean age, 10.66), and 39 typically developing children (mean age, 10.82). As part of a game, each child held the handle of a robotic arm, trying to capture animals that had escaped from a zoo. An animal would appear at a target location 8 cm away; if the child reached the target in time, the animal was captured and the child was given a point.

“Analyses revealed that all groups were able to effectively adapt their arm movement,” stated Dr. Mostofsky’s group. “However, generalization patterns were markedly different. There was a significant interaction between diagnostic group and relative generalization to targets 2 and 3. Posthoc analyses revealed this difference was due to significantly greater generalization of the autism group in the intrinsic (proprioceptive) coordinate system as compared to typically developing children. In contrast, there was no significant difference in generalization between ADHD and typically developing children.”

Regression analyses revealed that among all groups, generalization in the intrinsic (proprioceptive) coordinate system (ie, to target 3) was a significant predictor of social ability, such that greater social impairment was predicted by increased force for target 3, noted Dr. Mostofsky and colleagues. “Further,” the researchers concluded, “for the children with autism, increased force for target 3 predicted impaired social interaction. In addition, increased generalization to target 3 also predicted impaired imitation ability, as assessed on a praxis examination, as well as impairment in motor control.”

Children with autism rely heavily on proprioception, unlike children with other developmental motor impairments or typically developing children.

PROVIDENCE, RI—Children with autism spectrum disorder form a representation of internal models that places an unusually strong reliance on proprioception, according to research presented at the 39th National Meeting of the Child Neurology Society.

“This anomalous motor learning is specific to autism spectrum disorder, rather than a general deficit of all populations with developmental motor impairments, as children with ADHD did not generalize differently than typically developing children,” reported Stewart H. Mostofsky, MD, research scientist at the Kennedy Krieger Institute and Associate Professor of Neurology, Johns Hopkins University School of Medicine, Baltimore, and colleagues. “Our results suggest that autism-associated impairment in understanding actions of others may be a consequence of the fact that in learning to perform actions, children with autism place a greater than normal reliance on their own proprioception while discounting the visual consequences of their actions.”

The researchers analyzed 25 children with autism (mean age, 10.31), 16 with ADHD (mean age, 10.66), and 39 typically developing children (mean age, 10.82). As part of a game, each child held the handle of a robotic arm, trying to capture animals that had escaped from a zoo. An animal would appear at a target location 8 cm away; if the child reached the target in time, the animal was captured and the child was given a point.

“Analyses revealed that all groups were able to effectively adapt their arm movement,” stated Dr. Mostofsky’s group. “However, generalization patterns were markedly different. There was a significant interaction between diagnostic group and relative generalization to targets 2 and 3. Posthoc analyses revealed this difference was due to significantly greater generalization of the autism group in the intrinsic (proprioceptive) coordinate system as compared to typically developing children. In contrast, there was no significant difference in generalization between ADHD and typically developing children.”

Regression analyses revealed that among all groups, generalization in the intrinsic (proprioceptive) coordinate system (ie, to target 3) was a significant predictor of social ability, such that greater social impairment was predicted by increased force for target 3, noted Dr. Mostofsky and colleagues. “Further,” the researchers concluded, “for the children with autism, increased force for target 3 predicted impaired social interaction. In addition, increased generalization to target 3 also predicted impaired imitation ability, as assessed on a praxis examination, as well as impairment in motor control.”

Despite therapeutic advances in diabetes management, the majority of patients with diabetes are unable to achieve glycemic targets proven to reduce the burden of the disease. This burden not only involves the quality of life of patients with diabetes who experience the complications of this disease; it also includes the burden to society. One out of every five health care dollars is spent on caring for someone with diabetes—the majority on treating the complications.¹

Major barriers to patients’ ability to achieve glycemic goals include the need to make behavioral changes, lack of awareness of glycemic levels, and fear of hypoglycemia.²

Q: Is self-monitoring of blood glucose worthwhile in diabetes?

Studies have shown a benefit from self-monitoring of blood glucose (SMBG) in patients using insulin but not in those taking oral antidiabetic drugs. However, the American Diabetes Association recommends that patients with diabetes monitor their glucose once daily if they are being treated with noninsulin therapy and at least three times daily if they are taking insulin.³

Guidelines from the American Association of Clinical Endocrinologists (AACE) state that patients taking noninsulin or once-daily insulin therapy who have not achieved A1C targets should monitor at least twice daily, while those at target should monitor at least once daily. Those taking multiple daily injections should perform SMBG at least three times per day. If patients experience frequent hypoglycemia, AACE suggests monitoring glucose more often.⁴

The A1C test provides the “big picture,” the average daily glucose level during the previous 90 to 120 days, and correlates with end-organ impact. It does not identify glycemic variability, hypoglycemia, or hyperglycemia.

By contrast, SMBG patterns provide day-to-day data that can be used to select and manage glucose control programs and ultimately optimize a patient’s A1C. SMBG provides a measure of the specific pharmacologic impact of medications and, through feedback, allows design and implementation of physiologic insulin-replacement programs.

One example of SMBG is to have patients monitor glucose in pairs (ie, pick a meal each day and do a premeal and two-hour postmeal reading) and ask them to keep a log or download the data from their meter in the office. This type of monitoring can be enlightening and self-empowering for the patient in that it can provide valuable information regarding the glycemic response to the particular meal.

Intensive glycemic management has been shown to reduce the incidence and progression of diabetic complications. However, it is associated with an increase in severe hypoglycemia. This is worrisome for both patients and providers, as severe hypoglycemia has been associated with an increase in risk for mortality. SMBG can assist patients in understanding how their lifestyle affects their diabetes, as well as identifying hypoglycemia for those who may have hypoglycemia unawareness (ie, who lack the relevant symptoms).

Q: What is continuous glucose monitoring (CGM)?

CGM devices give real-time readouts of current glucose levels. They utilize a subcutaneous sensor that is inserted in the abdomen and worn for 3 to 7 days (depending on which device is used). The sensor sends an electronic signal to a receiver worn by the patient.

There are three major CGM devices that have been approved by the FDA and are available for both personal and professional use. Health care providers can purchase the units and have patients wear them for retrospective analysis; this is a reimbursable expense. All available CGM devices measure glucose values in the interstitial fluid. The sensor reads electrical current produced by the same glucose-oxidase reaction that is utilized by glucose meters that patients use to perform fingersticks for home monitoring.

Currently available CGM systems need to be calibrated at least twice daily. Sensor calibration entails the pairing of the fingerstick value with the sensor value from the interstitial space. Calibration confirms sensor accuracy during various points by “teaching” the sensor the glucose value that corresponds with the electrical current signal.

There is a known physiologic lag time that occurs between fingerstick and sensor values. This lag time is typically up to 15 minutes but is increased with rapidly changing glucose values.

Q: What are the benefits of CGM?

Recent studies have shown CGM can improve A1C without increasing the incidence of hypoglycemia.⁵

CGM systems have both low and high glucose threshold alarms that can be set to alert once the threshold is reached. The newest generation devices can also predict hypoglycemia or hyperglycemia by tracking rate of change, and users can be alerted to a potential event. This would then allow them to take appropriate action, such as consuming food or carbohydrates or taking insulin as necessary. (Before taking any action, the glucose should first be confirmed by SMBG.)

Software programs allow for review of glucose data, which can assist in identifying trends not appreciated by typical SMBG testing (such as nocturnal hypoglycemia and meal-time excursions). This allows for adjustment of insulin regimens to reduce the incidence of these events.

Q: Can CGM replace SMBG?

While CGM can provide much more detail regarding glucose trends and patterns, it is not a replacement for SMBG. CGM should not be used as a replacement for SMBG to dose insulin for meal- or activity-related adjustments. All dosing decisions should be based on the SMBG.

Currently, CGM is indicated for patients 18 or older, in conjunction with SMBG for the purpose of improving glycemic control:

• to identify and aid in management of glycemic patterns not recognized with typical SMBG

• to prevent glycemic excursions of hypoglycemia and hyperglycemia.

Its use is supported by ADA and AACE guidelines for glucose monitoring.

Q: Who would benefit from CGM?

Suitable candidates for CGM include those with a high degree of glycemic variability, those with hypoglycemic unawareness, shift workers, patients who use insulin pumps, athletes, and women who are planning to become or are pregnant. Patients should work closely with their health care team and perform regular SMBG.

It has been suggested that patients need comprehensive training and follow-up visits to fully understand the large amount of data that they can be confronted with, in order to fully benefit from these devices.⁶ While the accuracy is improving, there are a few limitations to this technology, including false alarms. Studies have also shown a positive correlation between sensor wear time (hours per week) and greater reductions in A1C.⁵

Conclusion
Glucose monitoring is a necessary tool—for patients as well as providers—that assists in identifying how patients’ lifestyles affect their diabetes.

Despite therapeutic advances in diabetes management, the majority of patients with diabetes are unable to achieve glycemic targets proven to reduce the burden of the disease. This burden not only involves the quality of life of patients with diabetes who experience the complications of this disease; it also includes the burden to society. One out of every five health care dollars is spent on caring for someone with diabetes—the majority on treating the complications.¹

Major barriers to patients’ ability to achieve glycemic goals include the need to make behavioral changes, lack of awareness of glycemic levels, and fear of hypoglycemia.²

Q: Is self-monitoring of blood glucose worthwhile in diabetes?

Studies have shown a benefit from self-monitoring of blood glucose (SMBG) in patients using insulin but not in those taking oral antidiabetic drugs. However, the American Diabetes Association recommends that patients with diabetes monitor their glucose once daily if they are being treated with noninsulin therapy and at least three times daily if they are taking insulin.³

Guidelines from the American Association of Clinical Endocrinologists (AACE) state that patients taking noninsulin or once-daily insulin therapy who have not achieved A1C targets should monitor at least twice daily, while those at target should monitor at least once daily. Those taking multiple daily injections should perform SMBG at least three times per day. If patients experience frequent hypoglycemia, AACE suggests monitoring glucose more often.⁴

The A1C test provides the “big picture,” the average daily glucose level during the previous 90 to 120 days, and correlates with end-organ impact. It does not identify glycemic variability, hypoglycemia, or hyperglycemia.

By contrast, SMBG patterns provide day-to-day data that can be used to select and manage glucose control programs and ultimately optimize a patient’s A1C. SMBG provides a measure of the specific pharmacologic impact of medications and, through feedback, allows design and implementation of physiologic insulin-replacement programs.

One example of SMBG is to have patients monitor glucose in pairs (ie, pick a meal each day and do a premeal and two-hour postmeal reading) and ask them to keep a log or download the data from their meter in the office. This type of monitoring can be enlightening and self-empowering for the patient in that it can provide valuable information regarding the glycemic response to the particular meal.

Intensive glycemic management has been shown to reduce the incidence and progression of diabetic complications. However, it is associated with an increase in severe hypoglycemia. This is worrisome for both patients and providers, as severe hypoglycemia has been associated with an increase in risk for mortality. SMBG can assist patients in understanding how their lifestyle affects their diabetes, as well as identifying hypoglycemia for those who may have hypoglycemia unawareness (ie, who lack the relevant symptoms).

Q: What is continuous glucose monitoring (CGM)?

CGM devices give real-time readouts of current glucose levels. They utilize a subcutaneous sensor that is inserted in the abdomen and worn for 3 to 7 days (depending on which device is used). The sensor sends an electronic signal to a receiver worn by the patient.

There are three major CGM devices that have been approved by the FDA and are available for both personal and professional use. Health care providers can purchase the units and have patients wear them for retrospective analysis; this is a reimbursable expense. All available CGM devices measure glucose values in the interstitial fluid. The sensor reads electrical current produced by the same glucose-oxidase reaction that is utilized by glucose meters that patients use to perform fingersticks for home monitoring.

Currently available CGM systems need to be calibrated at least twice daily. Sensor calibration entails the pairing of the fingerstick value with the sensor value from the interstitial space. Calibration confirms sensor accuracy during various points by “teaching” the sensor the glucose value that corresponds with the electrical current signal.

There is a known physiologic lag time that occurs between fingerstick and sensor values. This lag time is typically up to 15 minutes but is increased with rapidly changing glucose values.

Q: What are the benefits of CGM?

Recent studies have shown CGM can improve A1C without increasing the incidence of hypoglycemia.⁵

CGM systems have both low and high glucose threshold alarms that can be set to alert once the threshold is reached. The newest generation devices can also predict hypoglycemia or hyperglycemia by tracking rate of change, and users can be alerted to a potential event. This would then allow them to take appropriate action, such as consuming food or carbohydrates or taking insulin as necessary. (Before taking any action, the glucose should first be confirmed by SMBG.)

Software programs allow for review of glucose data, which can assist in identifying trends not appreciated by typical SMBG testing (such as nocturnal hypoglycemia and meal-time excursions). This allows for adjustment of insulin regimens to reduce the incidence of these events.

Q: Can CGM replace SMBG?

While CGM can provide much more detail regarding glucose trends and patterns, it is not a replacement for SMBG. CGM should not be used as a replacement for SMBG to dose insulin for meal- or activity-related adjustments. All dosing decisions should be based on the SMBG.

Currently, CGM is indicated for patients 18 or older, in conjunction with SMBG for the purpose of improving glycemic control:

• to identify and aid in management of glycemic patterns not recognized with typical SMBG

• to prevent glycemic excursions of hypoglycemia and hyperglycemia.

Its use is supported by ADA and AACE guidelines for glucose monitoring.

Q: Who would benefit from CGM?

Suitable candidates for CGM include those with a high degree of glycemic variability, those with hypoglycemic unawareness, shift workers, patients who use insulin pumps, athletes, and women who are planning to become or are pregnant. Patients should work closely with their health care team and perform regular SMBG.

It has been suggested that patients need comprehensive training and follow-up visits to fully understand the large amount of data that they can be confronted with, in order to fully benefit from these devices.⁶ While the accuracy is improving, there are a few limitations to this technology, including false alarms. Studies have also shown a positive correlation between sensor wear time (hours per week) and greater reductions in A1C.⁵

Conclusion
Glucose monitoring is a necessary tool—for patients as well as providers—that assists in identifying how patients’ lifestyles affect their diabetes.

Despite therapeutic advances in diabetes management, the majority of patients with diabetes are unable to achieve glycemic targets proven to reduce the burden of the disease. This burden not only involves the quality of life of patients with diabetes who experience the complications of this disease; it also includes the burden to society. One out of every five health care dollars is spent on caring for someone with diabetes—the majority on treating the complications.¹

Major barriers to patients’ ability to achieve glycemic goals include the need to make behavioral changes, lack of awareness of glycemic levels, and fear of hypoglycemia.²

Q: Is self-monitoring of blood glucose worthwhile in diabetes?

Studies have shown a benefit from self-monitoring of blood glucose (SMBG) in patients using insulin but not in those taking oral antidiabetic drugs. However, the American Diabetes Association recommends that patients with diabetes monitor their glucose once daily if they are being treated with noninsulin therapy and at least three times daily if they are taking insulin.³

Guidelines from the American Association of Clinical Endocrinologists (AACE) state that patients taking noninsulin or once-daily insulin therapy who have not achieved A1C targets should monitor at least twice daily, while those at target should monitor at least once daily. Those taking multiple daily injections should perform SMBG at least three times per day. If patients experience frequent hypoglycemia, AACE suggests monitoring glucose more often.⁴

The A1C test provides the “big picture,” the average daily glucose level during the previous 90 to 120 days, and correlates with end-organ impact. It does not identify glycemic variability, hypoglycemia, or hyperglycemia.

By contrast, SMBG patterns provide day-to-day data that can be used to select and manage glucose control programs and ultimately optimize a patient’s A1C. SMBG provides a measure of the specific pharmacologic impact of medications and, through feedback, allows design and implementation of physiologic insulin-replacement programs.

One example of SMBG is to have patients monitor glucose in pairs (ie, pick a meal each day and do a premeal and two-hour postmeal reading) and ask them to keep a log or download the data from their meter in the office. This type of monitoring can be enlightening and self-empowering for the patient in that it can provide valuable information regarding the glycemic response to the particular meal.

Intensive glycemic management has been shown to reduce the incidence and progression of diabetic complications. However, it is associated with an increase in severe hypoglycemia. This is worrisome for both patients and providers, as severe hypoglycemia has been associated with an increase in risk for mortality. SMBG can assist patients in understanding how their lifestyle affects their diabetes, as well as identifying hypoglycemia for those who may have hypoglycemia unawareness (ie, who lack the relevant symptoms).

Q: What is continuous glucose monitoring (CGM)?

CGM devices give real-time readouts of current glucose levels. They utilize a subcutaneous sensor that is inserted in the abdomen and worn for 3 to 7 days (depending on which device is used). The sensor sends an electronic signal to a receiver worn by the patient.

There are three major CGM devices that have been approved by the FDA and are available for both personal and professional use. Health care providers can purchase the units and have patients wear them for retrospective analysis; this is a reimbursable expense. All available CGM devices measure glucose values in the interstitial fluid. The sensor reads electrical current produced by the same glucose-oxidase reaction that is utilized by glucose meters that patients use to perform fingersticks for home monitoring.

Currently available CGM systems need to be calibrated at least twice daily. Sensor calibration entails the pairing of the fingerstick value with the sensor value from the interstitial space. Calibration confirms sensor accuracy during various points by “teaching” the sensor the glucose value that corresponds with the electrical current signal.

There is a known physiologic lag time that occurs between fingerstick and sensor values. This lag time is typically up to 15 minutes but is increased with rapidly changing glucose values.

Q: What are the benefits of CGM?

Recent studies have shown CGM can improve A1C without increasing the incidence of hypoglycemia.⁵

CGM systems have both low and high glucose threshold alarms that can be set to alert once the threshold is reached. The newest generation devices can also predict hypoglycemia or hyperglycemia by tracking rate of change, and users can be alerted to a potential event. This would then allow them to take appropriate action, such as consuming food or carbohydrates or taking insulin as necessary. (Before taking any action, the glucose should first be confirmed by SMBG.)

Software programs allow for review of glucose data, which can assist in identifying trends not appreciated by typical SMBG testing (such as nocturnal hypoglycemia and meal-time excursions). This allows for adjustment of insulin regimens to reduce the incidence of these events.

Q: Can CGM replace SMBG?

While CGM can provide much more detail regarding glucose trends and patterns, it is not a replacement for SMBG. CGM should not be used as a replacement for SMBG to dose insulin for meal- or activity-related adjustments. All dosing decisions should be based on the SMBG.

Currently, CGM is indicated for patients 18 or older, in conjunction with SMBG for the purpose of improving glycemic control:

• to identify and aid in management of glycemic patterns not recognized with typical SMBG

• to prevent glycemic excursions of hypoglycemia and hyperglycemia.

Its use is supported by ADA and AACE guidelines for glucose monitoring.

Q: Who would benefit from CGM?

Suitable candidates for CGM include those with a high degree of glycemic variability, those with hypoglycemic unawareness, shift workers, patients who use insulin pumps, athletes, and women who are planning to become or are pregnant. Patients should work closely with their health care team and perform regular SMBG.

It has been suggested that patients need comprehensive training and follow-up visits to fully understand the large amount of data that they can be confronted with, in order to fully benefit from these devices.⁶ While the accuracy is improving, there are a few limitations to this technology, including false alarms. Studies have also shown a positive correlation between sensor wear time (hours per week) and greater reductions in A1C.⁵

Conclusion
Glucose monitoring is a necessary tool—for patients as well as providers—that assists in identifying how patients’ lifestyles affect their diabetes.

As a recently retired physician who worked in family practice, palliative care, and occupational medicine for more than 30 years, I read “Is it time to drug test your chronic pain patient?” (J Fam Pract. 2010;59:628-633) with interest. I myself suffer from arthritis in the neck and low back, for which a medical school colleague prescribed a very low dose of hydrocodone prn several years ago. I believe my resident physician may have read your article right before my last office visit; he suggested a drug screen was appropriate for me because hydrocodone is a “high-risk” medication.

I understood, of course, and readily agreed. After all, I did thousands of these screens during my years of practice—at a cost of about $5 per test. The authors of your article apparently did not research the average retail cost of the test, stating only that it is “inexpensive.” Imagine my surprise when I saw the bill—$676 for the drug screen alone. My insurer readily paid its portion of the “allowable” charge ($434).

The medication itself is wonderful; it helps keep me functioning and costs me about 8 cents per pill, so I won’t complain too much. But I suspect that most of your readers would be surprised by the true cost of this “inexpensive” test at a major medical school.

Mack Tyner, MD
Gainesville, Fla

As a recently retired physician who worked in family practice, palliative care, and occupational medicine for more than 30 years, I read “Is it time to drug test your chronic pain patient?” (J Fam Pract. 2010;59:628-633) with interest. I myself suffer from arthritis in the neck and low back, for which a medical school colleague prescribed a very low dose of hydrocodone prn several years ago. I believe my resident physician may have read your article right before my last office visit; he suggested a drug screen was appropriate for me because hydrocodone is a “high-risk” medication.

I understood, of course, and readily agreed. After all, I did thousands of these screens during my years of practice—at a cost of about $5 per test. The authors of your article apparently did not research the average retail cost of the test, stating only that it is “inexpensive.” Imagine my surprise when I saw the bill—$676 for the drug screen alone. My insurer readily paid its portion of the “allowable” charge ($434).

The medication itself is wonderful; it helps keep me functioning and costs me about 8 cents per pill, so I won’t complain too much. But I suspect that most of your readers would be surprised by the true cost of this “inexpensive” test at a major medical school.

Mack Tyner, MD
Gainesville, Fla

As a recently retired physician who worked in family practice, palliative care, and occupational medicine for more than 30 years, I read “Is it time to drug test your chronic pain patient?” (J Fam Pract. 2010;59:628-633) with interest. I myself suffer from arthritis in the neck and low back, for which a medical school colleague prescribed a very low dose of hydrocodone prn several years ago. I believe my resident physician may have read your article right before my last office visit; he suggested a drug screen was appropriate for me because hydrocodone is a “high-risk” medication.

I understood, of course, and readily agreed. After all, I did thousands of these screens during my years of practice—at a cost of about $5 per test. The authors of your article apparently did not research the average retail cost of the test, stating only that it is “inexpensive.” Imagine my surprise when I saw the bill—$676 for the drug screen alone. My insurer readily paid its portion of the “allowable” charge ($434).

The medication itself is wonderful; it helps keep me functioning and costs me about 8 cents per pill, so I won’t complain too much. But I suspect that most of your readers would be surprised by the true cost of this “inexpensive” test at a major medical school.

Mack Tyner, MD
Gainesville, Fla

The Current Procedural Terminology (CPT) code set for 2011 includes several changes of interest to ObGyns. These include 1) guideline clarifications regarding wound debridement and obstetric care codes; 2) new codes for subsequent observation care; micro-remodeling of the bladder neck; insertion of a vaginal after-loading device; and 3) a lab code for detecting amniotic fluid in cervicovaginal secretions (using the AmniSure kit).

There is also a new code for vaccine counseling that will have an impact on you if your practice offers the human papillomavirus (HPV) vaccine to patients younger than 19 years.

There are changes to Medicare this year that you should take note of if you care for these patients, particularly in the area of preventive visit billing.

CPT and Medicare changes both took effect on January 1. The Health Insurance Portability and Accountability Act (HIPAA) requires that insurers accepted the new codes on that date.

Changes to the CPT code set

OBSERVATION CARE

One of the biggest headaches for medical practices has been standardized coding and billing for observation care that lasts more than 1 day. In the past, payers accepted a problem E/M for Day 2 of observation care, or instructed practices to code an unlisted E/M service. Now, you may report all care rendered in the observation setting with the addition of three new codes for subsequent care:

99244 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: problem focused interval history, problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99225 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.

99226 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Note that each of these codes 1) “suggests” the status of the patient for each level of billing, and 2) includes a typical time. This means that, unlike the observation care admission codes or the observation admission/same-day discharge codes, time that is spent with the patient, or on the unit, may be used to select the code—if you document 1) the requirement that more than 50% of the typical time was spent on counseling or coordination of care, or both, and 2) a detailed description of this activity.

WOUND MANAGEMENT

Codes for wound debridement were given a facelift with the addition of a new guideline that addresses both surgical and medical debridement. The surgical debridement codes, (11042–11047) are now reported on the basis of the depth of tissue removed and the surface area of the wound. This means that codes 11040 and 11041 were deleted to make room for new and revised codes.

This change will mean that, when you report these codes, you will need to document more information to bill. It’s also understood that coding separately for debridement of dermis or epidermis at the same time you code for debriding underlying structures would be inappropriate.

CPT has also indicated that active wound management codes 97597 and 97598 can now be reported by physicians or nonphysician providers as long as the provider has direct (one-on-one) contact. These codes should be reported for skin-surface debridement only.

The new and revised codes (some of which have been published in CPT in nonsequential order) are:

11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

+11045 (new add-on code reported with 11042 only) each additional 20 sq cm or part thereof

11043 Debridement, muscle and/or facia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

+11046 (new add-on code reported with 11043 only) each additional 20 sq cm or part thereof

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

+11047 (new add-on code reported with 11044 only) each additional 20 sq cm or part thereof

97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

+95798 (add-on code reported with 97597 only) Each additional 20 sq cm, or part thereof.

TRANSURETHRAL RADIOFREQUENCY

Category III code 0193T, which described transurethral radiofrequency micro-remodeling for stress urinary incontinence, has been deleted and converted to a Category I CPT code, 53860 (Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence). The procedure includes a periurethral block and flushing the bladder with a lidocaine slurry, and can be performed in the office.

In all, the procedure requires nine treatment cycles during the session, but the code is billed only once. Catheterization and measurement of a voiding sample after the procedure are included in the code.

AFTERLOADING DEVICES FOR CLINICAL BRACHYTHERAPY

CPT revised—slightly—existing code 57155, and added code 57156 (Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy).

• Code 57155 was revised to clarify that only a single tandem is inserted into the uterus. There had been confusion earlier in this regard.
• The new code describes a procedure that may also include dilation of the vaginal canal to remove postradiation adhesions. That procedure also involves 1) placement of bladder and rectal catheters and 2) radiographic imaging to confirm placement, which are not coded separately.

CLARIFICATION OF OBSTETRIC GUIDELINES

Been having problems with payers and their interpretation of the delivery only, postpartum only, and delivery with postpartum care codes? CPT has, at last, clarified what you can, and cannot, bill in those circumstances. (Keep in mind, however, that you may not unbundle these procedures if more extensive care is provided: Most payers want you to bill the global OB care code that includes antepartum, intrapartum, and postpartum care.)

In some cases (such as Medicaid), the payer stipulates that only the physician who actually performed the delivery may bill for it, even if the delivering physician is covering for, or is a member of, the same group practice as the primary attending of record. The “delivery-only” codes should be reported when 1) an unaffiliated physician has delivered the baby but will not be providing any outpatient postpartum care or 2) the payer has specified this method of billing for the covering or affiliated provider.

CPT has clarified that delivery-only codes (59409, 59514, or 59612, 59620) include admission to the hospital, the admission history and physical exam, uncomplicated labor and delivery (including delivery of the placenta, or use of forceps or vacuum extraction). These codes do not include inpatient rounding or discharge day care after delivery (and, of course, include no outpatient postpartum care). When, as the delivering physician, you also provide inpatient postdelivery care, therefore, you may additionally bill subsequent hospital care codes and discharge day management codes (99231-99233, 99238-99239).

If the unaffiliated physician performs the delivery and also intends on providing outpatient postpartum care, the CPT codes for delivery with postpartum are to be reported (59410, 59515, 59614, 59622). In addition to the delivery, these codes include all inpatient and outpatient postpartum care. And finally, for those physicians who are only providing outpatient postpartum care, the code 59430, Postpartum care only, should be reported.

PLACENTAL ALPHA MICROGLOBULIN-1

A new code, 84112 (Placental alpha microglobulin-1 [PAMG-11], cervicovaginal secretion, qualitative), has been added to allow the clinical laboratory to bill for this immunoassay that detects amniotic fluid in the secretions. Physician work involves collection of the specimen but, under CPT rules, collection is included as part of any E/M service.

Note: An existing code for this test that is used by Blue Cross/Blue Shield payers (S3628) remains valid in 2011.

HPV VACCINE COUNSELING

Before January 1, 2011, if you counseled a patient about the HPV vaccine, you could report preventive counseling codes, such as 99401–99404, in addition to the vaccine administration code, 90471 (Immunization administration, 1 vaccine). Now, however, you have a new code for counseling and vaccine administration for a patient who is younger than 19 years—the age group most likely to be counseled about this vaccine. When you see, and counsel, such a patient before administering the vaccine, on the same date of service, code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profession; first vaccine/toxoid component), and 90649 for the quadrivalent or 90650 for the bivalent HPV vaccine.

If your patient is 19 years or older and requires counseling, continue to bill 99401– 99404 for counseling, with 90471 for immunization and 90649 or 90650 for the vaccine. Keep in mind: Whether you report 90460 or the 9940X codes, you are required to document the content of the counseling. Codes 9940X also require documentation of the duration of counseling.

INFLUENZA VACCINE

New codes have been established for the flu vaccine, but you won’t be using them: They are intended to address future pandemic strains of influenza. This year’s vaccine contains the H1N1 strain, but is coded as the normal seasonal flu vaccine, based on the type given:

90656 (preservative-free)

90658 (split virus)

90660 (intranasal)

90662 (enhanced vaccine for patients older than 65 years).

Changes to Medicare billing

Some of the coding and billing changes this year that have an impact on ObGyn practice come from the Centers of Medicare and Medicaid Services (CMS) and the Affordable Care Act.

TIMELY FILING

The Affordable Care Act calls for a reduction in the maximum time period for submission of Medicare fee-for-service claims. Before January 1, a provider had 15 to 27 months to submit first-time claims to Medicare. Now, these claims must be filed within a calendar year of the date of service. Exceptions can be made for retroactive entitlement or in situations in which there is a secondary payer.

PAYMENTS TO CERTIFIED NURSE MIDWIVES

Next, more good news—if you employ a certified nurse midwife (CNM) in your practice. Before January 1, Medicare reimbursed direct billing from a CNM at only 65% of the Medicare Physician Fee Schedule. Now, a CNM is paid the same as a physician when she (he) bills under her own number.

In the past, some practices billed for the services of a CNM under “incident to” rules, to capture the physician payment—but this also meant that the CNM could not see a new patient. Under the change I’m describing, all CNMs can bill Medicare directly; see new patients; and be paid the same as the physician is paid. In addition, CNMs are no longer required to be supervised by a physician when they perform diagnostic tests that fall under the scope of their practice.

ANNUAL WELLNESS VISIT

The Affordable Care Act extended preventive coverage to Medicare beneficiaries in the form of an annual wellness visit. The two new codes here have been valued based on a level 4-problem new and established E/M service:

G0438 Annual wellness visit, including personalized prevention plan services, first visit

G0439 Annual wellness visit, including personalized prevention plan services, subsequent visit

Payment for the initial visit is made only beginning the second year the patient is eligible for Medicare Part B—during the first year of coverage, only the Initial Preventive Physical Examination (IPPE) (the “Welcome to Medicare”) exam will be covered.

CMS has stated that only one physician will be paid for the initial visit; when the patient returns to the same or a new physician in the third year, only a subsequent visit will be paid. It is, therefore, important that this information be conveyed to any new physician who sees the patient.

The annual codes can be billed in addition to any other preventive service, such as G0101 or Q0091; no modifier is needed for this combination. Medicare has waived both the copayment and the deductible for the annual wellness visit, as well as all Medicare-covered preventive services that have been recommended with a grade of “A” (“strongly recommends”) or “B” (“recommends”) by the US Preventive Services Task Force.

The annual wellness visit requires seven elements at a minimum (i.e., you may document and perform more elements than this, but not fewer):

• Establish or update the patient’s medical and family history
• List her current medical providers and suppliers and all prescribed medications
• Record measurements of height, weight, body mass index (initial visit only), blood pressure, and other routine measurements
• Detect any cognitive impairment
• Establish or update a screening schedule for the next 5 to 10 years, including screenings appropriate for the general population, and any additional screenings that may be appropriate because of her particular risk factors
• Review the patient’s 1) potential (i.e., risk factors) for depression, based on use of an appropriate screening instrument, and 2) functional ability and level of safety based on direct observation or screening questions
• Furnish 1) personalized health advice and 2) refer her appropriately to health education or preventive services.

CMS has also indicated that, although they will pay for a problem E/M service and the annual wellness visit on the same date of service with a modifier -25 added to the E/M service, they expect this type of billing to be rare—because of the nature of the wellness visit, which is time-intensive. They also expect that, given these requirements, the patient will not be billed additionally for a noncovered preventive service.

We want to hear from you! Tell us what you think.

The Current Procedural Terminology (CPT) code set for 2011 includes several changes of interest to ObGyns. These include 1) guideline clarifications regarding wound debridement and obstetric care codes; 2) new codes for subsequent observation care; micro-remodeling of the bladder neck; insertion of a vaginal after-loading device; and 3) a lab code for detecting amniotic fluid in cervicovaginal secretions (using the AmniSure kit).

There is also a new code for vaccine counseling that will have an impact on you if your practice offers the human papillomavirus (HPV) vaccine to patients younger than 19 years.

There are changes to Medicare this year that you should take note of if you care for these patients, particularly in the area of preventive visit billing.

CPT and Medicare changes both took effect on January 1. The Health Insurance Portability and Accountability Act (HIPAA) requires that insurers accepted the new codes on that date.

Changes to the CPT code set

OBSERVATION CARE

One of the biggest headaches for medical practices has been standardized coding and billing for observation care that lasts more than 1 day. In the past, payers accepted a problem E/M for Day 2 of observation care, or instructed practices to code an unlisted E/M service. Now, you may report all care rendered in the observation setting with the addition of three new codes for subsequent care:

99244 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: problem focused interval history, problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99225 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.

99226 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Note that each of these codes 1) “suggests” the status of the patient for each level of billing, and 2) includes a typical time. This means that, unlike the observation care admission codes or the observation admission/same-day discharge codes, time that is spent with the patient, or on the unit, may be used to select the code—if you document 1) the requirement that more than 50% of the typical time was spent on counseling or coordination of care, or both, and 2) a detailed description of this activity.

WOUND MANAGEMENT

Codes for wound debridement were given a facelift with the addition of a new guideline that addresses both surgical and medical debridement. The surgical debridement codes, (11042–11047) are now reported on the basis of the depth of tissue removed and the surface area of the wound. This means that codes 11040 and 11041 were deleted to make room for new and revised codes.

This change will mean that, when you report these codes, you will need to document more information to bill. It’s also understood that coding separately for debridement of dermis or epidermis at the same time you code for debriding underlying structures would be inappropriate.

CPT has also indicated that active wound management codes 97597 and 97598 can now be reported by physicians or nonphysician providers as long as the provider has direct (one-on-one) contact. These codes should be reported for skin-surface debridement only.

The new and revised codes (some of which have been published in CPT in nonsequential order) are:

11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

+11045 (new add-on code reported with 11042 only) each additional 20 sq cm or part thereof

11043 Debridement, muscle and/or facia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

+11046 (new add-on code reported with 11043 only) each additional 20 sq cm or part thereof

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

+11047 (new add-on code reported with 11044 only) each additional 20 sq cm or part thereof

97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

+95798 (add-on code reported with 97597 only) Each additional 20 sq cm, or part thereof.

TRANSURETHRAL RADIOFREQUENCY

Category III code 0193T, which described transurethral radiofrequency micro-remodeling for stress urinary incontinence, has been deleted and converted to a Category I CPT code, 53860 (Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence). The procedure includes a periurethral block and flushing the bladder with a lidocaine slurry, and can be performed in the office.

In all, the procedure requires nine treatment cycles during the session, but the code is billed only once. Catheterization and measurement of a voiding sample after the procedure are included in the code.

AFTERLOADING DEVICES FOR CLINICAL BRACHYTHERAPY

CPT revised—slightly—existing code 57155, and added code 57156 (Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy).

• Code 57155 was revised to clarify that only a single tandem is inserted into the uterus. There had been confusion earlier in this regard.
• The new code describes a procedure that may also include dilation of the vaginal canal to remove postradiation adhesions. That procedure also involves 1) placement of bladder and rectal catheters and 2) radiographic imaging to confirm placement, which are not coded separately.

CLARIFICATION OF OBSTETRIC GUIDELINES

Been having problems with payers and their interpretation of the delivery only, postpartum only, and delivery with postpartum care codes? CPT has, at last, clarified what you can, and cannot, bill in those circumstances. (Keep in mind, however, that you may not unbundle these procedures if more extensive care is provided: Most payers want you to bill the global OB care code that includes antepartum, intrapartum, and postpartum care.)

In some cases (such as Medicaid), the payer stipulates that only the physician who actually performed the delivery may bill for it, even if the delivering physician is covering for, or is a member of, the same group practice as the primary attending of record. The “delivery-only” codes should be reported when 1) an unaffiliated physician has delivered the baby but will not be providing any outpatient postpartum care or 2) the payer has specified this method of billing for the covering or affiliated provider.

CPT has clarified that delivery-only codes (59409, 59514, or 59612, 59620) include admission to the hospital, the admission history and physical exam, uncomplicated labor and delivery (including delivery of the placenta, or use of forceps or vacuum extraction). These codes do not include inpatient rounding or discharge day care after delivery (and, of course, include no outpatient postpartum care). When, as the delivering physician, you also provide inpatient postdelivery care, therefore, you may additionally bill subsequent hospital care codes and discharge day management codes (99231-99233, 99238-99239).

If the unaffiliated physician performs the delivery and also intends on providing outpatient postpartum care, the CPT codes for delivery with postpartum are to be reported (59410, 59515, 59614, 59622). In addition to the delivery, these codes include all inpatient and outpatient postpartum care. And finally, for those physicians who are only providing outpatient postpartum care, the code 59430, Postpartum care only, should be reported.

PLACENTAL ALPHA MICROGLOBULIN-1

A new code, 84112 (Placental alpha microglobulin-1 [PAMG-11], cervicovaginal secretion, qualitative), has been added to allow the clinical laboratory to bill for this immunoassay that detects amniotic fluid in the secretions. Physician work involves collection of the specimen but, under CPT rules, collection is included as part of any E/M service.

Note: An existing code for this test that is used by Blue Cross/Blue Shield payers (S3628) remains valid in 2011.

HPV VACCINE COUNSELING

Before January 1, 2011, if you counseled a patient about the HPV vaccine, you could report preventive counseling codes, such as 99401–99404, in addition to the vaccine administration code, 90471 (Immunization administration, 1 vaccine). Now, however, you have a new code for counseling and vaccine administration for a patient who is younger than 19 years—the age group most likely to be counseled about this vaccine. When you see, and counsel, such a patient before administering the vaccine, on the same date of service, code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profession; first vaccine/toxoid component), and 90649 for the quadrivalent or 90650 for the bivalent HPV vaccine.

If your patient is 19 years or older and requires counseling, continue to bill 99401– 99404 for counseling, with 90471 for immunization and 90649 or 90650 for the vaccine. Keep in mind: Whether you report 90460 or the 9940X codes, you are required to document the content of the counseling. Codes 9940X also require documentation of the duration of counseling.

INFLUENZA VACCINE

New codes have been established for the flu vaccine, but you won’t be using them: They are intended to address future pandemic strains of influenza. This year’s vaccine contains the H1N1 strain, but is coded as the normal seasonal flu vaccine, based on the type given:

90656 (preservative-free)

90658 (split virus)

90660 (intranasal)

90662 (enhanced vaccine for patients older than 65 years).

Changes to Medicare billing

Some of the coding and billing changes this year that have an impact on ObGyn practice come from the Centers of Medicare and Medicaid Services (CMS) and the Affordable Care Act.

TIMELY FILING

The Affordable Care Act calls for a reduction in the maximum time period for submission of Medicare fee-for-service claims. Before January 1, a provider had 15 to 27 months to submit first-time claims to Medicare. Now, these claims must be filed within a calendar year of the date of service. Exceptions can be made for retroactive entitlement or in situations in which there is a secondary payer.

PAYMENTS TO CERTIFIED NURSE MIDWIVES

Next, more good news—if you employ a certified nurse midwife (CNM) in your practice. Before January 1, Medicare reimbursed direct billing from a CNM at only 65% of the Medicare Physician Fee Schedule. Now, a CNM is paid the same as a physician when she (he) bills under her own number.

In the past, some practices billed for the services of a CNM under “incident to” rules, to capture the physician payment—but this also meant that the CNM could not see a new patient. Under the change I’m describing, all CNMs can bill Medicare directly; see new patients; and be paid the same as the physician is paid. In addition, CNMs are no longer required to be supervised by a physician when they perform diagnostic tests that fall under the scope of their practice.

ANNUAL WELLNESS VISIT

The Affordable Care Act extended preventive coverage to Medicare beneficiaries in the form of an annual wellness visit. The two new codes here have been valued based on a level 4-problem new and established E/M service:

G0438 Annual wellness visit, including personalized prevention plan services, first visit

G0439 Annual wellness visit, including personalized prevention plan services, subsequent visit

Payment for the initial visit is made only beginning the second year the patient is eligible for Medicare Part B—during the first year of coverage, only the Initial Preventive Physical Examination (IPPE) (the “Welcome to Medicare”) exam will be covered.

CMS has stated that only one physician will be paid for the initial visit; when the patient returns to the same or a new physician in the third year, only a subsequent visit will be paid. It is, therefore, important that this information be conveyed to any new physician who sees the patient.

The annual codes can be billed in addition to any other preventive service, such as G0101 or Q0091; no modifier is needed for this combination. Medicare has waived both the copayment and the deductible for the annual wellness visit, as well as all Medicare-covered preventive services that have been recommended with a grade of “A” (“strongly recommends”) or “B” (“recommends”) by the US Preventive Services Task Force.

The annual wellness visit requires seven elements at a minimum (i.e., you may document and perform more elements than this, but not fewer):

• Establish or update the patient’s medical and family history
• List her current medical providers and suppliers and all prescribed medications
• Record measurements of height, weight, body mass index (initial visit only), blood pressure, and other routine measurements
• Detect any cognitive impairment
• Establish or update a screening schedule for the next 5 to 10 years, including screenings appropriate for the general population, and any additional screenings that may be appropriate because of her particular risk factors
• Review the patient’s 1) potential (i.e., risk factors) for depression, based on use of an appropriate screening instrument, and 2) functional ability and level of safety based on direct observation or screening questions
• Furnish 1) personalized health advice and 2) refer her appropriately to health education or preventive services.

CMS has also indicated that, although they will pay for a problem E/M service and the annual wellness visit on the same date of service with a modifier -25 added to the E/M service, they expect this type of billing to be rare—because of the nature of the wellness visit, which is time-intensive. They also expect that, given these requirements, the patient will not be billed additionally for a noncovered preventive service.

We want to hear from you! Tell us what you think.

The Current Procedural Terminology (CPT) code set for 2011 includes several changes of interest to ObGyns. These include 1) guideline clarifications regarding wound debridement and obstetric care codes; 2) new codes for subsequent observation care; micro-remodeling of the bladder neck; insertion of a vaginal after-loading device; and 3) a lab code for detecting amniotic fluid in cervicovaginal secretions (using the AmniSure kit).

There is also a new code for vaccine counseling that will have an impact on you if your practice offers the human papillomavirus (HPV) vaccine to patients younger than 19 years.

There are changes to Medicare this year that you should take note of if you care for these patients, particularly in the area of preventive visit billing.

CPT and Medicare changes both took effect on January 1. The Health Insurance Portability and Accountability Act (HIPAA) requires that insurers accepted the new codes on that date.

Changes to the CPT code set

OBSERVATION CARE

One of the biggest headaches for medical practices has been standardized coding and billing for observation care that lasts more than 1 day. In the past, payers accepted a problem E/M for Day 2 of observation care, or instructed practices to code an unlisted E/M service. Now, you may report all care rendered in the observation setting with the addition of three new codes for subsequent care:

99244 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: problem focused interval history, problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99225 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.

99226 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Note that each of these codes 1) “suggests” the status of the patient for each level of billing, and 2) includes a typical time. This means that, unlike the observation care admission codes or the observation admission/same-day discharge codes, time that is spent with the patient, or on the unit, may be used to select the code—if you document 1) the requirement that more than 50% of the typical time was spent on counseling or coordination of care, or both, and 2) a detailed description of this activity.

WOUND MANAGEMENT

Codes for wound debridement were given a facelift with the addition of a new guideline that addresses both surgical and medical debridement. The surgical debridement codes, (11042–11047) are now reported on the basis of the depth of tissue removed and the surface area of the wound. This means that codes 11040 and 11041 were deleted to make room for new and revised codes.

This change will mean that, when you report these codes, you will need to document more information to bill. It’s also understood that coding separately for debridement of dermis or epidermis at the same time you code for debriding underlying structures would be inappropriate.

CPT has also indicated that active wound management codes 97597 and 97598 can now be reported by physicians or nonphysician providers as long as the provider has direct (one-on-one) contact. These codes should be reported for skin-surface debridement only.

The new and revised codes (some of which have been published in CPT in nonsequential order) are:

11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

+11045 (new add-on code reported with 11042 only) each additional 20 sq cm or part thereof

11043 Debridement, muscle and/or facia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

+11046 (new add-on code reported with 11043 only) each additional 20 sq cm or part thereof

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

+11047 (new add-on code reported with 11044 only) each additional 20 sq cm or part thereof

97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

+95798 (add-on code reported with 97597 only) Each additional 20 sq cm, or part thereof.

TRANSURETHRAL RADIOFREQUENCY

Category III code 0193T, which described transurethral radiofrequency micro-remodeling for stress urinary incontinence, has been deleted and converted to a Category I CPT code, 53860 (Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence). The procedure includes a periurethral block and flushing the bladder with a lidocaine slurry, and can be performed in the office.

In all, the procedure requires nine treatment cycles during the session, but the code is billed only once. Catheterization and measurement of a voiding sample after the procedure are included in the code.

AFTERLOADING DEVICES FOR CLINICAL BRACHYTHERAPY

CPT revised—slightly—existing code 57155, and added code 57156 (Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy).

• Code 57155 was revised to clarify that only a single tandem is inserted into the uterus. There had been confusion earlier in this regard.
• The new code describes a procedure that may also include dilation of the vaginal canal to remove postradiation adhesions. That procedure also involves 1) placement of bladder and rectal catheters and 2) radiographic imaging to confirm placement, which are not coded separately.

CLARIFICATION OF OBSTETRIC GUIDELINES

Been having problems with payers and their interpretation of the delivery only, postpartum only, and delivery with postpartum care codes? CPT has, at last, clarified what you can, and cannot, bill in those circumstances. (Keep in mind, however, that you may not unbundle these procedures if more extensive care is provided: Most payers want you to bill the global OB care code that includes antepartum, intrapartum, and postpartum care.)

In some cases (such as Medicaid), the payer stipulates that only the physician who actually performed the delivery may bill for it, even if the delivering physician is covering for, or is a member of, the same group practice as the primary attending of record. The “delivery-only” codes should be reported when 1) an unaffiliated physician has delivered the baby but will not be providing any outpatient postpartum care or 2) the payer has specified this method of billing for the covering or affiliated provider.

CPT has clarified that delivery-only codes (59409, 59514, or 59612, 59620) include admission to the hospital, the admission history and physical exam, uncomplicated labor and delivery (including delivery of the placenta, or use of forceps or vacuum extraction). These codes do not include inpatient rounding or discharge day care after delivery (and, of course, include no outpatient postpartum care). When, as the delivering physician, you also provide inpatient postdelivery care, therefore, you may additionally bill subsequent hospital care codes and discharge day management codes (99231-99233, 99238-99239).

If the unaffiliated physician performs the delivery and also intends on providing outpatient postpartum care, the CPT codes for delivery with postpartum are to be reported (59410, 59515, 59614, 59622). In addition to the delivery, these codes include all inpatient and outpatient postpartum care. And finally, for those physicians who are only providing outpatient postpartum care, the code 59430, Postpartum care only, should be reported.

PLACENTAL ALPHA MICROGLOBULIN-1

A new code, 84112 (Placental alpha microglobulin-1 [PAMG-11], cervicovaginal secretion, qualitative), has been added to allow the clinical laboratory to bill for this immunoassay that detects amniotic fluid in the secretions. Physician work involves collection of the specimen but, under CPT rules, collection is included as part of any E/M service.

Note: An existing code for this test that is used by Blue Cross/Blue Shield payers (S3628) remains valid in 2011.

HPV VACCINE COUNSELING

Before January 1, 2011, if you counseled a patient about the HPV vaccine, you could report preventive counseling codes, such as 99401–99404, in addition to the vaccine administration code, 90471 (Immunization administration, 1 vaccine). Now, however, you have a new code for counseling and vaccine administration for a patient who is younger than 19 years—the age group most likely to be counseled about this vaccine. When you see, and counsel, such a patient before administering the vaccine, on the same date of service, code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profession; first vaccine/toxoid component), and 90649 for the quadrivalent or 90650 for the bivalent HPV vaccine.

If your patient is 19 years or older and requires counseling, continue to bill 99401– 99404 for counseling, with 90471 for immunization and 90649 or 90650 for the vaccine. Keep in mind: Whether you report 90460 or the 9940X codes, you are required to document the content of the counseling. Codes 9940X also require documentation of the duration of counseling.

INFLUENZA VACCINE

New codes have been established for the flu vaccine, but you won’t be using them: They are intended to address future pandemic strains of influenza. This year’s vaccine contains the H1N1 strain, but is coded as the normal seasonal flu vaccine, based on the type given:

90656 (preservative-free)

90658 (split virus)

90660 (intranasal)

90662 (enhanced vaccine for patients older than 65 years).

Changes to Medicare billing

Some of the coding and billing changes this year that have an impact on ObGyn practice come from the Centers of Medicare and Medicaid Services (CMS) and the Affordable Care Act.

TIMELY FILING

The Affordable Care Act calls for a reduction in the maximum time period for submission of Medicare fee-for-service claims. Before January 1, a provider had 15 to 27 months to submit first-time claims to Medicare. Now, these claims must be filed within a calendar year of the date of service. Exceptions can be made for retroactive entitlement or in situations in which there is a secondary payer.

PAYMENTS TO CERTIFIED NURSE MIDWIVES

Next, more good news—if you employ a certified nurse midwife (CNM) in your practice. Before January 1, Medicare reimbursed direct billing from a CNM at only 65% of the Medicare Physician Fee Schedule. Now, a CNM is paid the same as a physician when she (he) bills under her own number.

In the past, some practices billed for the services of a CNM under “incident to” rules, to capture the physician payment—but this also meant that the CNM could not see a new patient. Under the change I’m describing, all CNMs can bill Medicare directly; see new patients; and be paid the same as the physician is paid. In addition, CNMs are no longer required to be supervised by a physician when they perform diagnostic tests that fall under the scope of their practice.

ANNUAL WELLNESS VISIT

The Affordable Care Act extended preventive coverage to Medicare beneficiaries in the form of an annual wellness visit. The two new codes here have been valued based on a level 4-problem new and established E/M service:

G0438 Annual wellness visit, including personalized prevention plan services, first visit

G0439 Annual wellness visit, including personalized prevention plan services, subsequent visit

Payment for the initial visit is made only beginning the second year the patient is eligible for Medicare Part B—during the first year of coverage, only the Initial Preventive Physical Examination (IPPE) (the “Welcome to Medicare”) exam will be covered.

CMS has stated that only one physician will be paid for the initial visit; when the patient returns to the same or a new physician in the third year, only a subsequent visit will be paid. It is, therefore, important that this information be conveyed to any new physician who sees the patient.

The annual codes can be billed in addition to any other preventive service, such as G0101 or Q0091; no modifier is needed for this combination. Medicare has waived both the copayment and the deductible for the annual wellness visit, as well as all Medicare-covered preventive services that have been recommended with a grade of “A” (“strongly recommends”) or “B” (“recommends”) by the US Preventive Services Task Force.

The annual wellness visit requires seven elements at a minimum (i.e., you may document and perform more elements than this, but not fewer):

• Establish or update the patient’s medical and family history
• List her current medical providers and suppliers and all prescribed medications
• Record measurements of height, weight, body mass index (initial visit only), blood pressure, and other routine measurements
• Detect any cognitive impairment
• Establish or update a screening schedule for the next 5 to 10 years, including screenings appropriate for the general population, and any additional screenings that may be appropriate because of her particular risk factors
• Review the patient’s 1) potential (i.e., risk factors) for depression, based on use of an appropriate screening instrument, and 2) functional ability and level of safety based on direct observation or screening questions
• Furnish 1) personalized health advice and 2) refer her appropriately to health education or preventive services.

CMS has also indicated that, although they will pay for a problem E/M service and the annual wellness visit on the same date of service with a modifier -25 added to the E/M service, they expect this type of billing to be rare—because of the nature of the wellness visit, which is time-intensive. They also expect that, given these requirements, the patient will not be billed additionally for a noncovered preventive service.

We want to hear from you! Tell us what you think.