TB Nurse Network Meeting

Wednesday, July 24, 201810:00-11:30 AM ET

Conference call in number: 1-888-557-8511Access Code: 254-487-3 #

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Agenda

Announcements• Upcoming events & webinars

Questions From A TB Survivor• Have you supplemented TB treatment with probiotics?

Discussion• TB Nursing Certification, Fall 2018• Re-establishment of MIACET• Billing for TB Services: Survey Results

Announcements

Next meeting Wednesday, October 17th, 2018• Topic: TBD. Suggestions? Contact mcguirkh@michigan.gov

Sunstrum Seminar• Off for the summer, seminars will begin again in September 2018

TTT TST Workshop Webinars• Interested in taking the Train the Trainer for the TST Workshop?

Rutgers Global TB Institute: TB Nurse Case Management Webinars• Looking for a nurse to present on August 24th (Friday)

• Any case that you feel presented some challenges with nursing case management that others could learn from. Can be ongoing or past.

• Also looking for 2019 presenters• Dates can be set by presenter

SNTC Webinar Series Coming Soon

Title When TB is the Least of Their Worries...

AboutThis webinar series examines the many challenges patients may encounter in conjunction with tuberculosis. This series helps healthcare professionals identify these challenges and provide strategies for support and intervention.

Schedule

• Corrections - August 23, 2018 | 12:00 PM ET• Opioids - September 13, 2018 | 12:00 PM ET• Homelessness - October 2018• Immigrants - November 2018• Refugees - December 2018• Additional Topics - Spring 2019

Format Webinars

Audience Physicians, nurses, and health professionals working with patients with TB and LTBI.

CE Continuing education credits have been applied for.

Tri-State TB Intensive Workshop

• Date: September 25-27, 2018• Time: 8:30 AM – 4:30 PM• Location: 1980 West Broad Street, Columbus, Ohio, 43224• Brochure is here:

https://www.michigan.gov/documents/mdhhs/Save_the_date_620193_7.pdf• More information: Amy Lewis lewisa1@Rutgers.edu

Day 1: LTBI Focus• Diagnosis and treatment of LTBI• Use of TST vs IGRA• Strategies to improve treatment completion and patient education• B1/B2 immigrants

Days 2-3: TB Disease Focus• Epidemiology, transmission & path, chest radiography, lab methods for diagnosis,

treatment, managing adverse drug reactions, extra-pulmonary TB, drug resistant TB, role of TB nurse case management, TB and diabetes, substance abuse, case studies.

www.Michigan.gov/TB Training & Education Educational Events & Presentations

TB Publications

Late-onset paradoxical reactions 10 years after treatment for tuberculous meningitis in an HIV-negative patient: a case report.• Paradoxical reactions (PRs) during TB treatment are well-established. However, little is

known about PRs presenting as a new lesion after the completion of treatment, especially in TB meningitis cases.

• A 27-year-old female, with history of completing treatment for TB meningitis 10 years ago, was admitted to a hospital due to headache and worsening of pre-existing visual disturbance.

• MRI revealed new tuberculomas in the left sylvian fissure. Repeatedly negative PCR and culture suggested this was not a relapse of TB meningitis

• Diagnosed with late-onset post-treatment PRs and treated with oral corticosteroids, tapered off over 1 year. Eventually, the symptoms were relieved, and the tuberculomas disappeared.

• Clinicians should consider the possibility of PRs long after the completion of TB meningitis treatment.

TB Publications

Detection of Mycobacterium tuberculosis in urine by Xpert MTB/RIF Ultra: a useful adjunctive diagnostic tool in HIV-associated tuberculosis.• "In January 2017, the World Health Organization recommended the Xpert® MTB/RIF

Ultra assay (Ultra) for tuberculosis (TB) diagnosis. Ultra offers improved analytical sensitivity when compared with the initial Xpert® MTB/RIF (Xpert) assay for the detection of Mycobacterium tuberculosis.

• We present a case from Uganda demonstrating Ultra positivity in urine from an HIV-infected patient presenting with altered mental status and urinary incontinence, and no other signs of active pulmonary or extrapulmonary TB. This represents the first published instance of a diagnosis of extrapulmonary TB made on the basis of a positive urine Ultra assay. The use of Ultra on urine may be a useful addition to the diagnostic armamentarium for disseminated TB in persons with HIV co-infection. The diagnostic accuracy of urine Ultra should be characterized further via prospective studies.”

Questions From A TB Survivor

Have you supplemented TB treatment with probiotics?

1. What are the known digestive health effects of TB treatment?2. Does anyone prescribe probiotic supplements during TB treatment?3. What are the effects of TB treatment on gut microbiota?

2018 TB Nursing Certification Course

• Date: Tentatively 10/15 – 10/16/18• Okemos, MI• Audience: Public health nurses, target those newer to the field of TB• Content…

o Should we eventually update and stick to the Michigan TB Case Management course? Or keep the content more flexible, based on request?

o Virginia example:• 2 trainings a year, 1 for new nurses and 1 for experienced nurses

www.Michigan.gov/TB Training & Education Educational Events & Presentations

Re-establishing the Michigan Advisory Committee for the Elimination of TB (MIACET)

• MIACET was formed in 1992 by a group of representatives from both private and public agencies with the goal of developing strategies and recommendations for the elimination of tuberculosis in Michigan. The 2012 MIACET Guidelines can be found here.

• Mission Statement: MIACET promotes effective management of persons in Michigan who are affected by tuberculosis and works toward statewide tuberculosis elimination.

• Vision Statement: The vision of MIACET is the elimination of tuberculosis in Michigan.

Possible Projects:• TB billing• Updating the Michigan TB Program Manual and the Michigan TB Tool Kit• Consensus on TB testing recommendations, specifically when to re-test and which result to

take as true, from the 2017 CID/IDSA/ATS TB diagnosis publication• LTBI:

• 3HP and SAT recommendations• Creating and strengthening surveillance for LHDs• Outreach to private providers for testing and treatment (LTBI toolkit like Pennsylvania’s)

Email Helen if interested in joining: mcguirkh@Michigan.gov

Billing for TB Services: Survey Results

Background:• Some MI HDs incur expenses for TB testing and treatment services (TB disease and LTBI) that can

be billed to Medicaid• There are no recommendations or best practices for billing for TB services and Medicaid does

not have official stance on using codes for these services

Proposal: Survey HDs to• Understand why some HDs are not billing for TB services, and• Assess how other HDs bill and successfully get reimbursed for TB services

Results:• Ran from: 1/31/18 - 3/5/18• 59 people responded from 30 MI HDs (27 public health nurses, 32 finance)

• What PMS (practice management system) do you use? Insight (52%)

• What types of payments and/or insurance does your HD accept? Medicaid (100%), cash payments (93%), commercial/private insurance (77%), etc.o Average payer-mix: Medicaid Managed Care (37%), Commercial insurance (24%), Medicaid

(traditional) (20%), etc.

• What insurance companies do you contract with?

• What billable services does your HD offer? Immunizations (100%), hearing and vision screening (93%), STI testing and treatment (87%), lead testing (83%), etc.

General Billing Questions

What TB services are offered at your HD?

Does your HD currently bill for TB services?

70%

30%

Yes

Service % replied

TB Testing 97%

In-Person DOT 77%

LTBI treatment 73%

TB disease treatment 63%

Medical consult (nurse) 63%

Medical consult (physician) 60%

eDOT 30%

Sputum induction 17%

No answer 3%

Those who don’t bill: Indicate the reason(s) your HD does not bill for TB services

Reason % replied

We do not see enough TB cases/LTBI to justify billingeach 50%

We do not bill for communicable diseases

We send these patients to outside organizations for services, who then bill the patient 38%

Poor reimbursement rates

each 25%Do not know which codes to use / Staff are not trained in coding and billing

No funding to provide staff training to code

Other

Most of our clients do not have insurance

each 13%Not enough staff time available for coding & billing / follow-up on unpaid bills

Difficulty getting on private carrier’s insurance lists

No answer

Those who don’t bill: How are these costs usually covered?

• Subsidized by local funds (75%), cash payers (fee-for-service paid by clients) (13%), no answer (13%)

Those who don’t bill: If you could bill for TB services, what services would you bill for?

Service type % replied

TB testing 78%

In-person DOTeach 67%

LTBI treatment

Physician consultation (LTBI & active TB)each 56%

eDOT

Nurse consultation (LTBI & active TB) 44%

Chest x-ray 22%

Labs

each 11%Translation line

Sputum induction

Those who bill: Who does your HD currently bill for TB services?

100%

73%

14%5%

0%

20%

40%

60%

80%

100%

Medicaid(traditional) &Managed care

Commercial (private)insurance

Medicare Local employers

Comments• “Reimbursement rates are very poor for private insurance carriers, we do a lot of private pay TB

tests as well as Contractor Billing for TB tests.”• “We don't bill for nursing services. We may bill for TST, but do not provide IGRA testing currently.

We will encourage those covered by insurance to use the PCP for medication management, and provide meds for those not covered using general fund or bill the county directly for services including diagnostics and/or meds.”

Those who bill: What are the most pressing challenges your HD encounters when billing for TB services?

Service type % replied

Poor reimbursement rates 52%

None 24%

Difficulty getting on private carrier’s insurance lists 19%

Managing multiple Medicaid Managed Care contractseach 14%

Most of our clients do not have insurance

Difficulty working with Commercial and Medicaid health plans

each 10%Not enough staff time available for coding & billing / follow-up on unpaid bills

Inadequate or difficult billing software

Do not know which codes to use / Staff are not trained in coding and billing

Checking and entering eligibility information

each 5%No funding to provide staff training to code

We do not have a “referring provider” or we are not the primary care provider

No answer

Comments• “We currently only bill for TST placement and venous draws for QFT. We are currently getting denials for TST because we do not

have a "Referring Provider" or we are not the primary care provider”• “We only bill for TSTs and that is done through out immunizations program. In the next few months we will start billing for T-spots.”• “Inability to bill for nursing time”

Those who bill: What type of TB services does your HD bill for?

Service type % replied

TB testing 100%

LTBI treatment

each 14%Physician consultation (LTBI & active TB)

In-person DOT

Chest x-ray

each 5%Nurse consultation (LTBI & active TB)

eDOT

No answer

Those who bill: Billing Codes Overview

TB TESTING CHEST X-RAY

Code* TST QFT T-SPOT VenipunctureNon-specific

reaction to PPD w/o active TB

Encounter for screening for respiratory TB

Outpatient new or established

patientFront Lateral

86580

86480

86481

36415

ICD-10 R76.11

ICD-10 R11.1

99201-99215

71010†

71020†

Always reimbursed

Sometimes reimbursed

Never reimbursed

Key

*Codes are CPT unless otherwise stated†These codes were deleted 1/1/18, should now use codes 71045-71048 (http://www.m3meridian.com/resources/insights/cpt-2018-summary-changes/)

Those who bill: Billing Codes Overview

CPT Code TB Testing LTBI Txt Physician consult for TB disease

Physician consult for LTBI

Nurse consult for LTBI

Nurse in-person DOT eDOT

99201-99215

99201-99205

99211-99215

99201

99202

99203

99204

99211

99212

99213

99214

99215

99384-99386

99394-99396

36415

Always reimbursed

Sometimes reimbursed

Never reimbursed

Key

Thank you!

Meeting notes and presentations will be sent to everyone on the TB Nurse Network list and posted on our website.

Next TBNN meetingWednesday, October 17th, 2018

10-11:30 AM ET

Please contact Helen McGuirk with questions, comments, or suggestions for presentations and content:

mcguirkh@michigan.gov517-284-4957